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SIINJOkiJ 11N 1.01, NI1 FN\11111\dILNI:III .III ':%I. III Ill 1'%1(1%11 NI <br />SERVICE REQUEST <br />Type of Business or Property FACILITY IDM SERVICE REQUEST M <br />1 <br />L <br />CHECK IIILONG ADORE <br />BUSINESS NAME <br />OWNER OPERATOR <br />�'— <br />HOME or MAILNG ADDRESS <br />CNECM 11 Dll LING ADDPf!! <br />FAX ll <br />DATE: 2 <br />FALILIrY NAME <br />kin r / / <br />SITE ADDRESS <br />STATE/ /I LR <br />5D..1 Number Glma ion <br />S HI CH.C.d. <br />HOME or MAILING ADDRESS (il Diller.nl l,u,n 50e Add,.,$) <br />P I E: *01 <br />' <br />b Amount Pal <br />SN.el Nem. <br />CITY <br />S1AIE LP _ <br />Payment Type <br />Invo lee N liff &V <br />PHONE II E., <br />APNN <br />Wm USE APPLICATIONN <br />1 .I) I.-(, / ) , <br />PHONE 02 E" <br />SOS DISTRICT <br />LOCATION CODE <br />CONTIOWTOR /SERVICE REQUESTOR <br />REQUESTOR <br />1 <br />L <br />CHECK IIILONG ADORE <br />BUSINESS NAME <br />sq Mq <br />yF 4T 120 <br />PNOxE1 En <br />HOME or MAILNG ADDRESS <br />FAX ll <br />DATE: 2 <br />Assueno Q To: <br />kin r / / <br />CITY - C I <br />STATE/ /I LR <br />BILLING ACKNO\1'LEDGENIENT L the mhdch5lened property or business owner, operator or authorized agent of some. <br />acknowledge that all site and+or project specific ENs 1RONMI-wrAL lfESLTii Dt. P SRrnusi hourly charges associated with this prgtect <br />or acu%it N% Ill be billed to me or my business as identified on this fomh. <br />1 also ecrdfy that I have prepared this application and that the work to be performed will be done in accordance with all SAN fOArR IN <br />COUNT-YOrdmamr Codes. Slandtos,TST4TL and RAC <br />APPLICANT'S SIGNATURE: '�l 'i ,; t_QS�_lry-�� a-=�L-� DATE; <br />I'ROPEHiI'/ fit]INE.CSOwNE RI OPER.\IOH1\I.L.YLGEH ❑ ollak.\I IINIHIZEuAr.i <br />If 4Plv( mrrr not rhe Biu e„ Patin) proof of authorization In sign is required 7trtr <br />AUTHORIZATION TO RELEASE INFORMATION: �Vhcn iprihclhlc. 1, the uwner or operator of the propertylocated a1 the <br />above sire address. hcrcbl authorize the lelcw Of in} and all rc,uhs, geutechmcal data ander envuonntentat� sic ,uscss. <br />information to the Ssc Jusllt Ix. ( ol;NrY Ent u:Il\Lti � rAL Ill \Lill Dt.PARTNIENT a5 soon as it is available and at the same lune i11s <br />provided tome or my represenlain c. <br />TYPE IN SERVICE REQUESTED: <br />cmmvr a: <br />(�C {nen tz ala Uhf <br />1y � <br />Iort (1� f 1i'RC�C0.� d1ALAU- cvm <br />V <br />sq Mq <br />yF 4T 120 <br />ACCRPTE'D BY: <br />CL r,A -es L <br />EMPLOYEE M: <br />DATE: 2 <br />Assueno Q To: <br />kin r / / <br />EMPLOYEE #'. <br />DATE: <br />Data Service Completed (if already completed): <br />SERVICE CODE <br />P I E: *01 <br />Fell Amount: <br />b Amount Pal <br />Payment Date <br />Payment Type <br />Invo lee N liff &V <br />hitch IT <br />Received B <br />EHD 48-02-045 <br />REVISED 11/1712003 <br />SR FORM (Golden Rod) <br />cFM�F T <br />O <br />?3�1? <br />CO <br />