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SEP.VICT:REQUEST �. <br /> Type of Business or Property FACILITY 10# Q n SERVICE REQUEST# <br /> f, l +C CCC nr, PA d S To 66 <br /> OWNER/OPERATOR BILLING PARTY❑ <br /> FACILITY NAME <br /> SrrE ADDRESSI <br /> Str�.r H�.nOr DU�dwn 1 Cn. l� 1 � Stw�am. Tm Sw.� <br /> Mailing Address (If Different from Site Address) <br /> CITY '�}�. STATE ZIP <br /> _J UC, 7)C1 6�,1�f �— <br /> PHONE#1 APN# LANG USEAPPl1CATI0N# <br /> PNONE#2 BOS Dmiucr LOCATION CODE <br /> CONTRACTORI SERVICE REQUESTOR <br /> REQUESTOR BUMS PARTY , <br /> M SNS <br /> BUSINESS NALE I PHONE [v. <br /> MAWNG ADDRESS I FAX <br /> Cm" F `'�, n r, STATEzP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or businesa owner,opmtor or authorized agent of sena. ad nowiedgo Nat all site and/or project spedric <br /> PUULr HEALTH SERVICES EM IRGIGrEHTAL HEALTH ON2"houdy Uma(ges associated with Na project or acttvily will be billed to me or my business as identified on this for, <br /> 1 also cardly that I nave prepared this app lion and Nat Na Ot to be Performed Lei be done A a¢wdanca with ao SAN JQA COUNTY ONinenco Codas,Slarbards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE DATE <br /> PROPERTYI BDSwESS OWNER . ❑ dr CPEATCRINWWeR ❑ On1FAAlInI EDAGENr ❑ <br /> 1APPLrwTisnol9e6LLMPMn.Prodolweatuoonfosphwmw Tll/e <br /> AUTHORIZATION TO RELEASE INFORMATION:When app4cab{e,L tlme awnswoperawrof tlIe property locabd at cine above cite addreas.hereby autllodze the rolease of <br /> any and all results,geoledmical data arWw elrviwmtPsmtaystta assessmrnl'nlORI b ltq SAW JOAWn COUNTY PUBLIC HEALTH SERvICES ENVnawaENTAL HEALTH OMsal a soon <br /> as R 15 available and at be same ttme itis provided b me or my mpresalta o <br /> TYPE OF SERVICE REQUESTED: -T� -� <br /> i <br /> COMMENTS: <br /> PHYIVi E?" <br /> RECEIVED <br /> ' 2001 <br /> SAID JOAOUIN COUNT', <br /> PUBLIC HEAT Ili SFHV 10F` <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: i Ewer=)1 �C� <� DATE: <br /> ASSIGNED TO: - ErrtaYEE# DATE G) <br /> Date Service Completed Crf already completed): SERVICECOOE: PIE: <br /> Fee Amount 3 T _ Amount Paid _ Payment Date I <br /> I F� <br /> Payment Type J- Invoice `Check# Received By. <br /> r"�,' <br />