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SL-WCE r215-7UES Y <br /> FACILrrY lD EITACE REQUEST <br /> Type of Business or Property <br /> -�� ' " SILL24 PARTY C <br /> r , <br /> GwNEtI r'p 4Ar�a i <br /> FACUa^r NAME <br /> 5rrt ACaSs <br /> / � r <br /> Mailing Addrass ,(If Different froSi)h <br /> SATE,, ZIP <br /> ClrY <br /> c` r � <br /> t APH LAND USEA.PPS=TCN <br /> PKON£#S <br /> Ll •r <br /> PHQNE �r /%IZ I.'sL <br /> - CCHTRAGtCEi1 N C ak .R - <br /> Rz-nttETaxsusmss <br /> FAx <br /> # <br /> STATE ZP C C ) f <br /> Car L-� <br /> opesstor or Z herm"d agent of sone.aQ ww'edge T=ad sle mlej'a v <br /> eat <br /> BILiNG ACKN2&="L Gci�I9WT-. C tha� ProP Y es as d wdh I=prem or acedy Wil be holed M me or my business as idert�led on dais r� <br /> Puaix HEoL�S'Rv�S EV nRCMieiTAL HE+L-H CN=N haunt d i <br /> E also�rdfy Shave precared dais appficaticsa and that to work=be periarmed wd be d=ie�aa�arc�wilh ali Sm:C�arar+C�ttr t t rrJrraace Gades.Suras S`,1tc and <br /> } <br /> s <br /> Fsmik laws. <br /> DATE:��� <br /> AP?t:curr W-MATtr <br /> 9 <br /> PRCpcqTY l 8lr$7'a=;w— C CSA MAXAG.-R Q rsc-z ORum AGE`- G 71t 1 e <br /> yApw_cwrsax2sA8zfwc Mad ofanrosirisrequred <br /> AU7H0R1ZATlCN TO RELEASE iNFORMA i ON:When app�ab{L L the awner or aper of dao;mP"b=Md at Sae atxave side address heal a�hari.:I=n s n <br /> any and ad re utts,geotecmrz i data arKVcr anvuvruamMWlszie <br /> a atPs7C ralCrarradoaa 4D ftSiN r.AMM C.lXry Pr�C 4EAUH 5c�•'EjVRC &eGALHEAD soon <br /> as 3 s avaiffaCle and at the Mme trre t is pavuBd to me ar nay <br /> TYPte OF Sr-.vrc'RE.UE5+E']: <br /> Coeeeerrs~ � f � <br /> '�AYM ANT <br /> MAR 3 12004 <br /> jAMJ JOAQUIN COUN it <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> INSAEC:t7R'S$IGNATr1Rir i CCKrAACTaR'S SCXATUW– <br /> i <br /> APPRva Sr. /� 777- <br /> A ?4t�Ti7:. <br /> DATE <br /> �� - _ �f'_cS `'� 'P ISL <br /> Date Service Carnpleted (Ff aiready eampieted): <br /> Fee Amount <br /> Amu Paid U f '. '' Pnment Dateefl <br /> C.`aes«c: I Received <br /> Payment Type ��" Inveirx � <br />