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S0VACE REQUEST <br /> Type of Business or Property FACILITY IO,a ICE REQUEST <br /> Tl L� <br /> CiWNER I OPERATOR BILLING PARTY Cl <br /> FAQUFY NAME <br /> FAC k FlG <br /> SnACCRESS <br /> C 5�'set Yum§.r 0lregan Y T r �" • i7B� Suite <br /> Mailing Address (If(Different from Site Address <br /> c2(0CD .CAMI00 kAIK40, DO 3 F-00 <br /> CTTY STA i c ZtP <br /> SNO RAvm. <br /> PHONE,471 err- APN M LANs UsaAPPUCATiON 1 <br /> P"iONE.,'Z BOS CIST,ZICT I LCCAnaN COoE:' <br /> _ I <br /> CCNTRACTORISc4YIC REQUESTCR <br /> REQuESTCR S Sn_.131G PARTY Cl <br /> SCO-IT -1+4�t���#I I-L <br /> SusiNESS NAME ExT- <br /> HL. OErS10 6"ve, t o —lfo a <br /> MAILING ALcRus `AXW <br /> 1Lo P-Tq M c Do u) 6 { 1 <br /> C,I� �TAr-�. J M ATE 5 <br /> BILLING ACKNOWL20GEMEW: I. the undersigned property or business owner, operator cr autharind agent of same, a(rtn wtedge hat all site andicr prv*-t sce=-c <br /> P SUC`[EALTN Sc-Ril=E.-WnCrr.Me(AL SEA I.H CWMCN hauriy larges asscr aid with itis gm pr cr a=vity Will be Jled n me or my husiness as;denafied an this d nt. <br /> E also r-rafy hat I have prepared,his aaoiicatcn and hat he,Nsrx b ae performed wll done n s==nce,+rith ata SAH JCACuW C.:UNTY Qrrirnan�Codes,Standards,�iAi c and <br /> FEZZA0aws. <br /> APm-'VNT SIGNA7UR;E. ❑ATE <br /> PrOFTY�BUSINESSCwrtE� �iP��7GRi�1LLWiG �fr�ALfrFER�a.�(rfT <br /> .VAP.--c.wrs xat Rx-c p=i�d=dmcrrdcn�s*anus id i itta <br /> AU T dCRZA i ION T 0 FEL(SSE INFCRIMA—MCN:When acpii-tle.I,he owner or operator ci u"te pmpery'�ted at to atove site address,zereoy aurtarim he ret-,.ase cf <br /> any and ad results,gectecttn:csl data ander emnrcrrnenrdfsrte assessment inicrmawn t the SAM;CACLIN G'•UN7 Y P,ELIC�E UH;;e�V1Ca&mFCNmEc rrAtiL;Ear-,,I Cr+ls"C,4 as soca <br /> as it�avadahle and at the same the it is rrcvrded to are cr ry reVresemdve. <br /> i YPEOf SEawcc- <br /> G^,Mht�lTs: - I <br /> INSFEL,CR'S SIGNATURE: (:,^HTRA=R'S SICUATURS <br /> APPRCVED ay- <br /> Dam Service Completed ('rf already pmpfetsd): Scan C;of F I E <br /> Fm Amount Amount Paid + Payment Cate <br /> Payment Type Invoice r I C:tes c I Received 3y: � <br />