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SERVICE REQUEST <br /> Type of Business or Property FACILIjY ID# SERVICE3REQUESTS <br /> F 0OtC) iso <br /> OWNER I OPERaT� II BLLUXG PARTY❑ <br /> FacattY NAME <br /> %eV(l <br /> L <br /> SfTE ADDRESS w-, S+ <br /> sa+e Nam. I typ. Sint.f <br /> Mailing Address (If Different from Site Address) <br /> 2600 Canttwt, zr.-, IF-00D7 <br /> iSTATE ZIP <br /> Crrr Sa.. CA 01�k�83 <br /> PHOHE91 APNZ LANOUSEAPPUCAT10Nw <br /> (UO aZ3-x! 61 0r{3 -O33 -0 ( <br /> PHONE#2 90S DtsTRu:r LQuT)O <br /> H Coc :. ,. <br /> 60MR 1 SERVICE REQUESTOR <br /> REgUESTOR BILLING PARTY C1 <br /> �r weCG lu5 <br /> BUSINESS NAME <br /> 45,& 76 765-l66D <br /> MAILING AooRFss FAX ix <br /> � tvr ��Do��11 al� W� 65- - �apo�a <br /> 13 <br /> CITY p•Jalu...r; STATE A .A ' q 1 [ s <br /> BALING ACKNOWLEDGEMENT:1,the undersigned property or business owner,operator or authorized agent olf•fsun.,acknowledge l at all site and/or pcojed specfic <br /> PusLc HEALTH SERvas EwRcN TAL HEALTH ON ISrH houdy dtarges associated wdh this p pied or arlvitf will be bided to me Of my business as identdfed on this form <br /> I also certify that I have prepared this appfication and Cat me work m be perforated wd be done in amardance with an SArr ICA"Caw"arolmence Codes,Sfarrderds,STATE and <br /> FEDERAL laws. vViG i�,✓�� <br /> DALE: -7-11-0 <br /> 1 <br /> APPLICANT SiGNATU <br /> PROPERTY I SUSutESS OWNER ❑ Ca£RATCR I KUK<ZR ❑ OTHER AUTHop=AGENT [� b l a a ►� <br /> CAaP Lr-W it not cn Q/r.,o PaRrw pm(of wtharadton to sign is roq ww Ill. <br /> AUTHORIZATION TO RELEASE INFORMATION:When apprKable,L the owrwor operstor of Cie pro Perry boated at the above site address,hereby authortm the release of <br /> any and all resufts,geotechnical data arxilor mwi onmertaYslin assessment infCrrnadon to Cie SAN jGACU,COLAM Puauc HEALTH SERVCFS EwwctwerrAL HEALTH DNtwN as soon <br /> as it is avadable and at the same time t is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMHEM": <br /> PAYM lir P— <br /> RFr"- <br /> Shiv J"r Uiry COUNTY <br /> PUBLIC SERVICES <br /> ENVIRONMENTALLTH HEALTH DIV BION <br /> INSPECTOR'S SIGNATURE CONTRACTOR'S SIGHATUR£: <br /> APPROVED 9Y: 14 E%PLaY--t: ( DATE: L <br /> AssamEDTo- � �(.- �S� EsrPt.Ora-+--1 'i V DATE: <br /> Date Service Completed Cif already campleted): SERvscE Cotte P 1 E_ <br /> keeAmount r! � Amount Paid .� < vPayment Date <br /> t Type Invoice Check 3(� ` Received By: <br />