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SERVICE REQUEST <br /> FACILITY ID SERVICryE REQUEST:t <br /> Type of Business or Praperry uy, <br /> BIIUNG PNM <br /> CWNER1 CPERATOR _ <br /> `7 <br /> FACIuTy NAME F7 <br /> } �J� <br /> sus,a <br /> M <br /> SITE ADDRESS I+ <br /> ' $tr7a1 ama <br /> �-� Sh+w M+mtrfr drrttina <br /> tAaiVlny Address tIt Dlfferent from Site Address) <br /> STATE Zip <br /> elr. APN$ LAxoUSE APPueATTax <br /> PHORE 91 <br /> J L/�o 3 17- `a BOS DMTR1CT LOCAWN CODE <br /> Ext. <br /> PRONE 92 <br /> CONTRACTOR I SERVICE IREQUESTOR S LL.TIG PARTY lK <br /> REQUE=R <br /> 00,0— PHONE 4 EXT, <br /> Bus;NESS NAME � <br /> N . � - J%LJe 1=�� . <br /> � Gler ��.],ro-, r FAx4 <br /> _ <br /> f�IArLSNG ADORESs v i v z 1 ✓�>f"�1 +� D(i Q k ! X51 _ <br /> STATE ZIP Z <br /> CITY I / 1 fr, f I { <br /> e that ad]ite ardor <br /> project sCec�c <br /> ned property or business sumer,opatator or aufharuad agent of lama a b �d9 as Idersdlsed on d1a forrrL <br /> BILLING ACKF�aW EDS �E i"N I l the w�dersg hau p tltatges assaoared wm dus pgec�of act Y will be t led to ma or my <br /> P�ajc HEALTH SEES Eyyrq�W$1TAL HEALTH DtA tat *, vrdh aG SAN JOAC AH COUNTY Ordinance Codes.StaMmds,STATIE and <br /> I also certify that I have prepared the ap*200n and drat!ne work m be pertorrrred vril be done in acu�rdarxs <br /> FEDERAL taws- C a+ ►J c s L-Cf 2 v <br /> OAS <br /> APPUCW SO4ATUPE: <br /> CPE.ATORIM�ANA.GER d OTH7Aunt AGEW � Tlr1s <br /> P ROPF�TY 1 BUSINESS C M+E� a if rti E •,ay um!Pro&d auv-t 3d-to'AP 4—w'd auSt orlm the release of <br /> :When apf •t awnu or oporatar of the prupariy located at me a�sIu address.hereby <br /> AUTWCtRt7AT40N TO R LEAS INF I Tl Infomutian m dne SAN JaAGuw COIurTY PL�LrC HEALTH SERA$EN/iROruaENTAL HEAD+QNrsK7t+as soon <br /> any and al resutLS geote[3inxaf data arxiior ecru~�rrtaVsde aezent <br /> as d d avaianle and at the sarne stMA d is GfD"d� <br /> to me Of my raiartsertatire- <br /> TYPE OF SarxE REQUESTED: T �4 I 1 <br /> c s <br /> . oU <br /> E <br /> CONTRACTOR`S SIGNATURE_ <br /> INaPECTOR's StraNATURE; � DATE: �i <br /> EYPt.^Y�Th � <br /> MPRaVU eY EE DATE: <br /> E�P[.aY �: <br /> ASSK3NED TO: SERVICE COOE: P I E_ <br /> Date ServlCa Completed It alrasdy complated): <br /> Amount Paid ��-(o�i f Payment Oahe �� i)l D3 <br /> Fee AmounO Re:Wved ST.Paymetrt Type <br /> Invoice# ChtsClc# 3'�a,3 (o <br />