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SERVICE REQUEST <br /> Type of Business or Property FAClLFfY i0 SERVICE REQUEST 9 <br /> S 2-allGN -7 - I <br /> OWNER I OPERATO wQ&� � Pm U L 51LUNG PARTY <br /> FAc1UTY NAME Am � � � 3� <br /> SrrEADOUSS '�. �NJ MIN 4O L T DR <br /> Nvedw oir�tian S]rMtN+rne T sux►x <br /> Mailing Address jif Different kom Site Address) <br /> C" S TO C I--TO N CA Cl S-W : STATE zip <br /> PHONE 91 gr. APN# LAUD USE APPLKATION# <br /> (Zat)�t�- - SSsz <br /> PHONE V BOS Dt=cr . . LDCATfON CODE <br /> _ . <br /> CONTRACTOR I SERVICE REQUESTOR <br /> RI=nUESTOR A I� �� Bates Pax[Y <br /> BUSINESS NAraE 'Fe LCOS G I��01 PHONt:# �* <br /> Z l� l �S h c . to a �c i <br /> liWlNaAnoREss t-�od Avg FrobylAeN4 <br /> BILLING ACKNOWLEDGEMENT:I. the undersigned property or business owner,opmtor or authertxed agent of same,advowi*a that an sua andlor project spedk <br /> PUBIC HEALTH SE; nEs ENVttiONhI NTAL HEALTH ONtSION hOuAy dtatgas assoaated witti this ptojaC or a=vq wM be Wed W me or my business as ldentiliM on talo form. <br /> 1 also certti�fy,�IBM. I have prepared this appftcatwn and that the work to be pertormed wig be done in accordance whh ag SAN JOAGUrN COUNTY Oerhanca Codes Slandards,STATE and <br /> FEcERAL IOM . `7 n <br /> Appur—w SIGNATuRE.__ 6/f'vJ DATE: I z <br /> PROPERTYISU&WESSOWNER Q OPERATOR I MANAGER ❑ OTHER AtlydoR=AGENT C3 <br /> rYAPRxwyr1%rade BtUNGFU7rY pgo!of authatftat►Or!r0 Sir hrmord Titre <br /> AUTHORt7ATION TQ ELEASE INFQRMATION:When appfKable,L the owner or operator of the property Ionated at the above site address,hereby authorila the release of <br /> any and all results.9eoteMniwt data andW efMmnmwtaVStte assessment Information to the SAN JDA"COUNTY PUBIC HEALTM SERwmrs EXwRONW-NTAL HEAL"H OMSON as soon <br /> as it Is available and at me same time a is provided so me or my representative. <br /> TYPE OF SERvice REgUESTEO: <br /> COMMENTS: <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE= <br /> APPRova BY: EatPt. 9: DATE: <br /> ASSIGNE D T0: EMPLOYEE t. DATE: <br /> Date Service Completed (d already completed): StYtGECODE: ... P/E: <br /> Fee Amount: Amount Paid Payment Date <br /> Payment Type Invoice Check Received By: <br />