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i <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY 10# SERVICE REQUEST# <br /> &0z `�v ! Sew <br /> Baunc PARTY❑ <br /> OWNER/OPERATOR ' <br /> FACILITY NAME . <br /> tt�✓p,-, 5"]-o�L L237— 321go/ ,1 <br /> SITE ADD ESS 5 1 41� K� k �7 <br /> 9 3 a. Nuror oma se..x m. T1 <br /> Mailing Address (If Different from Site Address) <br /> CITY STATEC/n zip <br /> PHONE#1 L`T• APN# LAND USE APPLICATION# <br /> (Zjy) `) 39 <br /> PHONE#2 BOS DISiRICi _ _ LOCATION CODE <br /> CONTRACTOR I SERVICE REDUESTOR <br /> REQUESTOR SLUNG PARrY)K <br /> BUsuiEssNAME PHONE# - <br /> 6-I/�G�i 67V1-3Liv•- Pw 6,4-C, �-✓/r:es 3-,,.c. /z� 3S5 2y3LW 3 <br /> < ^ <br /> MAILING ADDRESS -2 FAX 521 FJP/"(-.F d <br /> Cm Jl� l IfCJ STATE V"r7 ZIP �rj 27s <br /> BILLING ACKNOWLEDGEM'eNT:L the uridersigned property or limineu owner,operator or authoriudl agentofsame,admowledge that all 69 5andlor Project 3;0&o <br /> PueUc HEAaT 1 SEavas EwIRCHNENUl HEALTH omscei homy cninges associated wih this p*d or advoy wgi he Cited to me or my business as Identified on this form <br /> 1 also carol,that I have prepared Ne appkaeon and Mat Ne work to be performed will be done In aomNanre will,all SAN JOjA"COUNTY ONinence Codes.Standards,STATE and <br /> FEDERAL laws �/(�//'//� am . ' <br /> APPUCANT SIGNATURE: DATE: '�Ln�U1�. l <br /> �� J <br /> PRDPERTYIBuso&ss OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT ?lJ�,,J /A4U/K50./ <br /> Title '— <br /> YAcrS.CwTsncrdreaurGPunr.praoraeudrarlratlonmean tr rpuiee <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.L Ne owner or operator of Mn pmpedy located at the above site address,hereby wthortre the mlease of <br /> any and atl mull,,geotechnical data anolor errvimnmenaVsile assessment nformadon to the SAN JGAOUw CO2M PuaUC HEALTH SERvaS ENNRONMENTAL HEALTH Oms10N as soon <br /> as i b available and at the same time a Is provided b me or my represemallo. <br /> TYPE OF SERicE REQUESTED: <br /> COMMENTS: PAYM VED <br /> REC'E <br /> F Eg 1 p 2003 <br /> PU�OHaA HEAL�HONSION <br /> EPMRONMENTf4 <br /> INSPECTOR'S SIGNATURE: CONfRACt0R`SS�TSIGNATURE: <br /> APPROVED BY: EMPLCYEEt. -TIC)( {-T 'DATE -T <br /> ASSIGNED To: EMPLDYEE#: v r g DATE <br /> Date Service Completed (if already completed): SERVICE CODE: ... -P I E. <br /> Fee Amount I Amount Paid Payment Date <br /> Payment Type Invoice# Check 4 Received By. <br />