Laserfiche WebLink
SAN JUAQt:IN Co[N'Tv ENVH2()NMEN I•AL HEALTH DEPARTMENT <br /> SERVICE REQLiFST <br /> ype of Business or Property FACILITY 10# SERVICE REQUEST k <br /> OWNER/OPERATOR CtEcx if BILLRI3 AODA ESS❑ <br /> FAcrtrY NAME <br /> SnAmRfss G SCtCct`w"vvi#O �{ ( Ad 5LN Cl <br /> 2Lf suw N.n ' Lvot= 31xM Nea.e CIT0. <br /> kOMEOfMAILING ADDRESSIII Different from Site Acidrew ) 4,p -7 <br /> $RBeI NumDse sLea!Neme _ <br /> CITY STATE ZIP <br /> L &\ C � (.t�z L-, n_ <br /> pNoiati et' APN a LAND USE APPULA,IVN# <br /> I Zo)) 'L- <br /> Pmcw02 E" QOS DaS'A,cr } LOCATUN CODE <br /> t xc)) UV3-5 Lak --{- <br /> CONTRACTOR / SERVICE RI:QUESTOR <br /> REaIIESTOR <br /> C"Et.Y:d@uuNoanDnEss❑ <br /> f` <br /> BUSINESS NAME A-e C C4 41 Err. <br /> Z-(o 3 �_ <br /> NOME or MAlt.rac ADDRESS FAX e <br /> City STATE • \ ZIP C)p f J <br /> BILLING ACKNOWLEDGEMENT 1, the undccsiylted property or bucinesa owner, operator Or authorized agent III %ame <br /> acknowledge that all spit and or I.rofeet \ptedic III,\1 I1+ Dt r\RIMI NI hotel} charges associnted with i1w. <br /> 01 11411% lh a III he hilicd i0 me or m\ busine><e.as IdrnuficJ un Ihl,fi,uu <br /> al,u ccnlf's that I haat prepared this application and 0wdic ,\ori, to be performed %ill be done in accurdonca with all S\ <br /> Ofth weex C'w4s.SrwaArnb. Si tit and Frt;i NAt laws. l <br /> API'LK ANT'S SIGNATURE: <br /> 1trrrli'l.kl1 NI 'I,1„0acr4a 01.1'R\rrNl/ ❑ ,17111Th Al 111im"I n \I., NI Cl <br /> f5(?f IRf f.prulQ of nutAernrirlwl rn %ign It rryrrin d rifle <br /> kI 1'II0RIZA I I0% 'Th RELEASE INFORMA'IJON: When upplicahlc, 1, die dwnrr to Operawr ul Ili, 1>rnprrty hrcnlcJ .li the <br /> ue„r situ Addrv%N. hcrcbs audwrrrr Il+c Icicaw tri :111? aid ail PeSults, geOitchnlcal data nnJau eneiruluncultl dile a-,r..Ilnrl:; <br /> IltitABtal1U11 it, dic S.\N, 21 r vjt ,\ L i 11 \t HI-%I III Ltu'AM MI-N I CS SDOn AS it Is il1'ail.thle slid ,11 the f.a111P Imw Ii <br /> pro\tded to me or m} represvitati\c Q <br /> TYPE OF SERVICE REQUESTED: C� <br /> cQaaEarS, -” ( 2 DEC�9 -7 OJ-3 C 09 ?0 <br /> �0 ?II <br /> Sq N q <br /> HEq rHDOPCV <br /> gRJMEIV <br /> AccEPTEO BY: EMPLOYEE N: �11 ) DATE: f�., OQ V j <br /> A3siaNED rO: EMPLOYEE IY: SJ OATE� /� —O 2; <br /> Date Servico Completed {if airnaay compieted)t st;twE CocE 1 PI E: <br /> Fee Amount: r22- 4 <br /> ', Amount Paid AlPayment Date <br /> PaymentType �j _ Invoice a Chock a 2 Recei ed By: <br /> 0` SR FORM tGultw, r: <br />