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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5 a <br /> OWNER/OPERATOR 1 �A BILLNG PARTY <br /> FACILITY NAME <br /> SIrEADORESS <br /> T StreK Numbv eirectlan SbM Hum Typ. � svue3 <br /> Mailing Address (if Different from Site Addressl <br /> j o?7O ✓Ci S/ ��� <br /> CITY/ STATE � ZIP <br /> PHONE <br /> 77 7 -377y e . APN# dOS-dff6 -/O LANDuSE�� u <br /> IIA <br /> PHONE#2 BOS DISTRICT _ - LOCATION CODE. <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REOUESTOR — BILLING Parr <br /> BUSINESS NAME <br /> MAILING ADORES <br /> JS <br /> Crn STATE LP <br /> BILLING ACKN �,/ /�i n / I agent of same, acknowledge that all site andlor project speccc <br /> PUBLIC HEALTH SE� �[,E V _ �1y1� 'r�f/s K billed to me or my business as identified an this lorm. <br /> I also certify that 1 � n all SAN JaAGwN CouNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL IawS. 6,":;- <br /> APPLICANT SIGNATCENTa DATE: <br /> lHr <br /> PROPERTY/ <br /> i'7/ ll✓ sign r=avr vd TW4 <br /> AUTHORIZATIC �kxated at the above site address,hereby authorize the release of <br /> any and all results. /ice � may/ <br /> PUBLIC HEALTH SERVICES ENVIRONMFHTAL HEALTH DMSAN as scan <br /> a5 it s available ar_ <br /> TYPE OF SERVICE <br /> COMMENTS: _ RECEIVED <br /> DEC 12 2008 <br /> SAN JOAOWNE <br /> ENjHp PAF <br /> INSPECTOR'S SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY: EYPLofEz1Y. �� DATE <br /> ASSIGNEDTO: FNPLOYEE#: DATE <br /> 1 1 <br /> Date Service Completed (if already completed): iiI SERVICE CODE: <br /> Fee Amount '/J Amount Paid O &D Payment Dateg <br /> Payment Type Invoice# Check# 1% C) - Received By: <br />