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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID 9 SERVICE REQUEST <br /> 602_ � 8 <br /> OWNER I OPERA �� BILLING PARTY } <br /> FACILITY NAME <br /> SRE ADDRESS <br /> -?S5`- Ty� <br /> Mailing Address (If Different from Site Address) <br /> 519--- E 9s`C.s5 z <br /> Crry STATE ZIP <br /> PW <br /> PHONE## Err. APNA LANOUSEAPPUCATiON9 <br /> PHONE#2 BOS DISTRICT ---[LD TION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR BUJNG PARTY❑ <br /> BUSINESS NAME PHONE It [u. <br /> MALING ADORES$ FAx# <br /> CITY STATE Zip <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner,operator or authorised agent of same, ad awfedge that aif site andlor project spearic <br /> PUBLIC HEALTH SERVICES ExwzCrv.rcNTAL HEALTH C)Na"hourty diarges a sedated with this projector activity wX be ba--d to me or my business as identified on Mr.twm. <br /> I also corWy that I have prepared Nis app5cabon and that Me work to be perfomred wd bo done in accardaurce with aA SAN JOAGLm CcuNrY OrWaanoa Codas,Standards,STATE and <br /> FEDERAL laws. <br /> APPLr SIGNATURE: DATE: <br /> PROPERTY/BUSYIE.SS OWNER OPERAT / ❑ OnKE1A THORRED AGENT ❑ <br /> YAPKjawris not Vv 6LLmprvorof r d"trition to I%=Is rvgf: ritte <br /> AUTHORIZATION TO RELEASE INFORMATION:When appkzble,L the owner or operator of Ow pro party boated at the above arta address,hereby aut xwr the rebatie of <br /> any and all recut geotechnical data an!or ertvironmerttaUsiie amasuTowt inbrmatbn b CIe SAN J4wj"COUNTY Puag HEALTH SF.RvtCFs ENvRotufxrAL HEALTH DM=N as soon <br /> as d is avadable and at the same time it is provided b me or my represattattvo_ <br /> TYPE OF SERY)CE REQUESTED: <br /> CoatuExrs: <br /> a <br /> 3- <br /> 60 <br /> INSPECTOR'S SIGNATU ' CONTRACPOR'S SIGNATURE: <br /> APPROVED BY• EsIPLIIYr? 71 DATE: OF <br /> 0 <br /> ASSiGNEDTO: _ L-Y EMPLOYEE# DATE: <br /> Date Service Comple r (rf already comp I 9tad): S&v>cECODE: ��r' PCE: 24 d <br /> Fee Amount: Jr ` " Amount Paid Payment Date <br /> Payment Type Invoice rk Checktt {31 Received By: <br />