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.. � 0 SERVICE REQUEST j <br /> Type of Business or Prop? FACl1 tTY 1D# SERVICE REQUEST K ! <br /> rz r C u c.-r4 ttA L a o 2_U--1!d <br /> OWNER I OPERAT`O'R BU>vJHG PARTY❑ <br /> DAr I`� N 2E1� <br /> FACILITY WE <br /> SITE AaaRESS 4 A W1115 RID <br /> sv..c N�.rW.. ofs.mon sa,�gym• .- . sort.r <br /> Mailing Address (If Different korn Site Address) <br /> C <br /> m G>..r GKT�NrArE Z / Z <br /> PHONE#1 ., EXT. APN# LAmu UsEAPPurThOH x <br /> 3-/tq--oma. <br /> PHQHE#i2 ELT. SOS D<sTRJ T L.ocAwmCont <br /> CONTRACTOR I SERACE REQUESTOR <br /> REQUESTOR BU.t NG P <br /> DO k/ <br /> BUSINE5s"EPHONE# / 3 acr <br /> V. 4 <br /> MAIuNG AouRm FAX 9 <br /> . Q • �3oK9 - Z� 8 <br /> CITY �j STATE BJP <br /> BILLING ACKNOWLEDGEMENT. 1, the undersigned property or business owndr,operator or authorized agent of same,adv aModge Mt alt 344 ardor pn*d spOC& <br /> Pueuc HEALTH SERvus EwacNhA1aAL Hucii oras*N houOt durges associated with this project or at th*win be Med to ms or my business as identified on ud,teen <br />�. t also corpfy shat 1 have prepared a Gcation bo done in aogadance With a4 SAN JOAOLAN COtATY Ordi la-,W Codes.Standards,STATE and <br /> PEDER&laws. <br /> APpucAur SJGmTuFw: 7' /7- a/ <br /> PROPERTYIBUSJHE,SSOWNER 0 OPERATORIMANAGER ❑ 0T1itAUtH4RUE0AGEHr <br /> YAmnr�wit (ftkLmprVao(wooreadwtosob Tia. <br /> IdTH 4R T N TO RELEASE INFgR :when applicable.L the owrur cr operat ord the property located at the atwve sits addross,hereby aut}rortte the rela>ise of <br /> any and aA results,geotechnical data amLlor wMrwmerttaifsb assewmertt inbmatbn to nhe SAN JoAam CGUWY Puux HEATH SERVCES ElrYvwKme4TAl HFJIL.H OtvOW as soon <br /> as it is avakbio and at the carne ttm?itis proMed to me or my rep wa tagm <br /> TYPE OF SLwcF REQUESTED: <br /> Id A FA GE AR.OA C 7—A rnlAIA T1,e MX1 eV <br /> COM1iF.Jfh'5: <br /> PAYMENT <br /> c>I <br /> �30 RECEfVED <br /> w JUL 1 / 2091 <br /> off- <br /> _✓% �53�., ,� 3 © �l u PALIBLI°HALT COUNTY <br /> Jrrlir+tilpo��y'A"' n /IQ ENVIRONMENTIr L.HEALTH L)IVf510N <br /> INSPECTOR'SSIGNATURE: CO 00ZOIFes SIGNATURE: <br /> APPRoYEo aT: EXPLOY—al. f DATE. ! (1 j <br /> AswmaTo: r\ '_ r. i� EriPLO mk !7 DATE: j I I + r ! <br /> Date Service Completed Cif already completed): 5EWMCOU1E: ' 7� � Pit E: d`Es7d j <br /> rc 1 Pa ment Date <br /> Fee Amount r ` �-- =Amount Md r �7 Y —71 -i I o l <br />► I <br /> Payment"typeinvoice# Check Fi Received By: <br /> k <br />