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116/20/2000 11:35 2094683 FIFTH FLOOR PAGE 01 <br />SE <br />cRVICE REQUEST <br />Type of Business or Property FACl1,ITY 1D # <br />SERVICE REQUEST rt <br />OWNER! OPERATOR G ✓� _ <br />ILUNG PAM Q <br />FaCtIrPY NAME <br />SRE Aoonss <br />se c to =Add,) L ! n( CDL. of 9L V:bMailing Address (lt Different from Ssame Hen <br />T Sous <br />CITY d/ l� STAiFri ZIP <br />APN# LA!(oUsEAPPUCADO <br />NM <br />PHONE#2 Exr BOS D <br />15iRJCT : , LOCATAN(•OOE:. ;. <br />CONTRACTOR! SERVICE REQUESTOR <br />REQuesTOR <br />❑ <br />i3i751NESS Ni4d! <br />V oAUYC <br />PNOYE {r` Ezz <br />12-I f7?1 C 1rC�` • &l� � - 7020 <br />MAILING Am= FAX <br />CITY ZszS W • t3ip,�fS.�ni�. ��u.� �!r0 8�-lost Z� <br />u 2�3/�nJ iL STATE d,4 ZIP <br />RING ACKNOWLEDGEI4[>;NT: l the UNemigned property or business Owner. operator or authortred agent of same, adv a flat all M18 andlor <br />FUGLC HEALTH SMMCt:S EN Paffl ENTAL HEALTH Oms;ON hauriy dmM,--- assodated with thi5p 9 ° 9 Fro. sQedfrc <br />project oradivity wrll be hRei d to me or my business a$ iderrtifted an ft fnrm. <br />I also cerdfy that 1 have preparzd this appscation and that the wo* to be perfamred Will be done in acaardance with al SAN Jct otm Cawry t exgrrce Codes. Sterrdards, SraTp and <br />FEOERALIaws //• <br />APPUCANr SrmATuRe: OV <br />GATE <br />PRGPERTYI EUSINaSS CWNER ❑ OPERATOR/ MANAGER Q Cr.4aAuTr CRC--' rAGGw ❑ f �i�+ vx � b-�z.c L6't. <br />11Ar7.,c-vr it t& the $y LMR -AM' prod of autlmih 2tlon to s;p k roqusn4 rl t re <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, L die owner or operator of the property located at the above site address, he authot¢e the release of <br />any and ail results, geoteclakal data and/or vr4ronment2ifsite assessment infurmadon to the SAN J04uiNf,qurrtY PuBUC Ht,a<7ti SEWICEs ErrvIRON)AU TAL HEX -,W Oms;cN as soon <br />as it is avacable and at the same Cone it is provided to me army repmsert a6p <br />