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SIN <br />Type of Business or Properly <br />OWNER I OPERATOR <br />FACUL A"ME <br />SrFIE AOORESS x,.J- N <br />$seri womper Vr.e1V�. <br />1rta11ing Address {it Different from Site AAddreanf <br />Crr7 <br />PItoNE i1 E'. <br />PrONE pZ LXT. <br />1 <br />SERVICE REQUEST 0. <br />FACILITY ID 9 SERVICE REQUEST 9 <br />mutt& PA.Rrr !7 <br />Ack–ni y St dall.ff" 1 Tra. I _ tots <br />STATE Zip , <br />CA APf� LANO USE APPLICATION I---](� <br />8CS1)43TRrCT LOCATION CODE <br />CONTRACTOR r SF-RVICE REQUESTOR <br />B[LLI9t3 PARTT�' <br />{�E�hIF974R _ <br />C <br />BUSINESS NAME — _ - - - -_ rpLj <br />FAx f <br />MAJUNGDRESS <br />Gr7 Sr.Ts <br />tm <br />Ifttr p4j{HpWLEEJGi MFS' I, Pie unaersk�ned property or bu$In�$$ owngt, oponlor of Guth arizisd agent of slime. a{Xnar+"s V101 Hl S"andlar project spec <br />Pu9LIC HEaLTH SERVICES ENvhpr,�l;t+Ft+TAL H&kTH OtYfSom hourly Uhatgns assod°afad wft h this ptojea or 2CIMty wit be GiW m me or my busL7asa as 4anufied on $fits faun. <br />f abo car9F Ihat I have prepared this appk:5kn and ;hal T* work to be pedom1ed vA be done in ecmrdanm wiM a/ SM li>zm CoUrM Ordinanea Codes. Slandanfs, STATE and <br />FEDERAL faro. <br />DATE: <br />APrUC"TSIcNATUAE.: <br />PoOPE,7Tr i BVSveESS C ""EA O OpE,aM7CA f I•tARAGER OMER AUntOOIZED AGIEW <br />I APPur—r ft Rd OW f UtjE1= F�'pr ar audfoerr+dan to Sign it r&**Pd f I t a <br />F ORIZATION TO RU EASE INFORMATION: When applicable, L 5,1e owner or aparatoror She property I=led al the ebuve site address, hereby auVwrikv Vie release of <br />any and ali rtsults, "olerrinira# data aniVor enviranrreA aVstte assessment Into rnaeon la the SAN JtkCuk CCUNTy PUeUC HEALTH SERVICE EtfVIROMmEHTAL HEALTH UrvhSretr as soon <br />._ . .. .. - - .. -- `-- .. – �u...u...r , — n, mr mmmA intadeE. <br />-AUX _AUU_Aa-I $ >1Z) LLULaH VSt,:80 66-91-6nV <br />