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T ` SERVICE REQUEST ✓�11e�'QQ, PT,.�s <br /> Type of Business or Property FACILITY ID# SERVIC REQUJ ST# <br /> C-0-1c r � ;�� Iva S4ud ypn- <br /> KG�r <br /> OWNER 10 TOR BLLLNG PARTY❑ <br /> g7tvec <br /> FAwry NAME <br /> � <br /> 01RSs <br /> 99 dw6n �Yw sw.i <br /> Mai lin Address (If Different from Site Address) - <br /> � /1 L � 9533 v <br /> CITY �` �- Z 9s3 <br /> MOVE91 E+T- APN# LANu USEAPPl1CAT10N# -- — <br /> (6cd 76 32c, -Z X53 -I20- y7 L PA-0- <br /> P"Ir 97z o8z a- BOS DIstRlcr LOCATION COBE <br /> CONTRACTOR I SERVICE REOUESTOR <br /> QUESTOR�I —_ BLLLwG PARTY❑ <br /> BUSINESS NAY PHONE# �• <br /> �'a l��e cars A tom} ert s L 6 76o z <br /> MALLING ADDRESS FAx �'S� — 3 ^T <br /> CITY / /�, Sr Z°' 9s 3 3 0 <br /> BILLING ACKNOWLEDGEMENT: I, the uodersgnod property or business own",operator or authari ad agent of same. ack aw"o Nat as site andtor project specific <br /> PUBLIC HEALTH SERvICES EiVaif.r E TIAL HEALTH Dm$gN hourly c targes associated with Nis project a aafvdy will be billed to me or my business as idenafied on N6 farm <br /> 1 also cartity that 1 %ave Preparej;app <br /> fiw and that Ne work lo be p"lomred WA be done in acmrd.T with as SAN JOAWn COt M Ordwn Codes,Standards,STATE and <br /> FEDERAL LTws. <br /> APPLJGNT TtIRE: G � LY DATE: UZ- <br /> PROPERTTIBuswE.SsOWWA ❑ 0 TOR1MuuGEx Aum <br /> ❑ 0THEnla �,1 <br /> uiEDACENr �fti�CC,I 1 tG.wL , e+' <br /> aAAnFwrsreeeYf? i P.vm.pwedrRwtratlon WSW is r.pwd rill• <br /> AUTHORIZATION TO RELEASE INFORMATION:When appikable,L No owner or opmatorof vw property located at Ne atwre site address.hereby audiortai ft misass of <br /> any and all resulN,geoiedmral dam anllor wrviaunentalfsda assosxrent itkntwtlun lo dw SAH JOAam COUNTY PLELiC HEALTH SERVICES @"RommEKTAL HEALTH Dms"m soon <br /> as It Is avadable and at Ine same time it is provided lo me or my mpresarm <br /> TYPE OF SERv10E REQUESTED: I <br /> ,/ <br /> n/�—G <br /> COYYEHrs: 2 VIS54 <br /> 3Z >V' UI <br /> 7 �7�oe2 111'�py A OP6 <br /> rnYivl l'v i <br /> 3 �{° " MAR 2 5 2002 °>t <br /> 36 <br /> `AN JOAC]UIN COUNT) <br /> V1PPB�A Nra ,� <br /> 1LT'I'SfRVICE _ <br /> YY*" <br /> INSPECTOR'S SIG RE: CONrRACTmeS SIGNATURE: <br /> APPROVED BT: EwtoT--t DATE: Z <br /> c L <br /> Ass cHm T0: EYPLOTEE# DATE: <br /> Date Service Completed (rf already completed): SamECODE: ZS P II— <br /> Fee Amount [� S Amountpaid Payment Date <br /> Payment Type Invoice# Check# Received By: <br />