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0 <br />SGWCE REQUEST <br />"Type of Business or Property <br />FACILITY ID # <br />SERVICE REQUEST# <br />OWNER 1 OPERATOR <br />CpMMFNFu: <br />BILUNG PARTY ❑ <br />FACILGY NAME r <br />0 I wl b �� <br />SrrsAGGREss <br />eauti0n <br />Selerafee <br />I <br />TM <br />auiba <br />Mai mg Address {If DiFererd(rdm Sita Address) <br />CtrY <br />STATE Zp <br />PNONE#1 <br />LANOUsEAPPLrATION# <br />Non #? <br />POS DSTRICr_. <br />Lqur=CooE.. <br />ON <br />BILLING ACKNOWLEDGEMeRT: 1, Ne unders4nad property, or business ovmer, operator or autnorked agent or same, acknowledge that all alta andlor project spedrx <br />PUSt1C HEALTH SWVIC@s ErmtW RQWrt HEALTH DMSIONhoury charges awdated w& Na project or amity wW be bMed to ma or MY business as idwlred en V00m. <br />m. <br />I also darty Nat I Terve prepared t* applicSton and that the work padomted wit ba done in ac oaldanat mlh al SAN Jak N1 COUNTY Crdiamm Codusc Standards, STATE and <br />FEPEnAL lain,- <br />APPLICANT SICRATURE: 4 ---- <br />PROPERTY!ELSINESSOv ❑ OPBUTORINMNAGM ❑ OTHsAURICPI2FDAGENr <br />HarneA.rxria rat@saerwePAarY yeddwrhar6aYrw teagnoraeY Tirle <br />AUTHORUATION TO RELEASGJ FORMATION: When appf=ble.t, Ne owner or operaforaf the property lOWWd at Ne Ob" CM addeesa. harabY audldlto the renin of <br />any and at resltlt% geolechni al data ardor en inowentaYSte assessment i*Matm m to SAN JQAduw COUNrY PUBLIC HE LLTH SEWCES EIMAMWIN rALHUIN OMGM ft Soot <br />a9 itba✓aYahk arld Bt No same tlmeitis pmaidCd to me err my mprpset»ative. <br />TYPE OF SERVICE Rrwrsmu: <br />Y <br />CpMMFNFu: <br />,We7AAWR7507 <br />r <br />0 I wl b �� <br />I <br />P �cE`vED <br />ON <br />BILLING ACKNOWLEDGEMeRT: 1, Ne unders4nad property, or business ovmer, operator or autnorked agent or same, acknowledge that all alta andlor project spedrx <br />PUSt1C HEALTH SWVIC@s ErmtW RQWrt HEALTH DMSIONhoury charges awdated w& Na project or amity wW be bMed to ma or MY business as idwlred en V00m. <br />m. <br />I also darty Nat I Terve prepared t* applicSton and that the work padomted wit ba done in ac oaldanat mlh al SAN Jak N1 COUNTY Crdiamm Codusc Standards, STATE and <br />FEPEnAL lain,- <br />APPLICANT SICRATURE: 4 ---- <br />PROPERTY!ELSINESSOv ❑ OPBUTORINMNAGM ❑ OTHsAURICPI2FDAGENr <br />HarneA.rxria rat@saerwePAarY yeddwrhar6aYrw teagnoraeY Tirle <br />AUTHORUATION TO RELEASGJ FORMATION: When appf=ble.t, Ne owner or operaforaf the property lOWWd at Ne Ob" CM addeesa. harabY audldlto the renin of <br />any and at resltlt% geolechni al data ardor en inowentaYSte assessment i*Matm m to SAN JQAduw COUNrY PUBLIC HE LLTH SEWCES EIMAMWIN rALHUIN OMGM ft Soot <br />a9 itba✓aYahk arld Bt No same tlmeitis pmaidCd to me err my mprpset»ative. <br />TYPE OF SERVICE Rrwrsmu: <br />CpMMFNFu: <br />P �cE`vED <br />SPU `OPEPjNEE HpEV\S10 <br />MSPECOOR's SrMTWW <br />CowntAGTGN'S SfGRAIURE: <br />- "INV <br />APPROVED Err <br />EMPL`:a'a: � DATE <br />O 3 <br />ASSIGNEDTO: J 1 19 C45. ;7'L/ <br />F.lIPIATffi. 3%3 DATE 9 3 <br />Date Service CompkInd (Rilreadycompletad): <br />sawnECooe:.. - 0' <br />'PIE <br />Fee Amount 2'7Vef <br />Amount Paid 79 OD P3ymwt0& <br />e3 <br />PaymentType <br />Received By: <br />E0 39Vd <br />NOMA HldId <br />EED889V60Z TS:L0 E00Z/LZ/80 <br />