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Iwo <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID SERVICE REQUEST» <br /> OWNER ERATORBW.WG PARTY <br /> P <br /> KH�LAK�+�1=, <br /> FACILITY NAME <br /> SREADDRESsC -� �1'C►� j� 1N41 W <br /> I6.mon sw.s <br /> Mailing Address (If Different¢oro Site Address) <br /> STATE ZIP <br /> PHOHE»T �T• APN# LAND USEAPPUCAT10N9 <br /> ( ) <br /> PHONE 92 aT- BOS DISTRICT LOCATION CODE. <br /> 0 RI SERVICE REOuESTOR <br /> REQUESTOR BILLING PARTY❑ <br /> BDslc ss `` G'_ ` �v t� - �- C� � ..f•+.iC- P ZNE tt <br /> �cAD�Drses� ��� FAxC <br /> CITY 1�•� SIA _ 7JP� <br /> BILLING ACKNOWLEDGEMENT: L the undersigned property or business owner,opmtor or authorized agent of sank ackadcdge that as site andfor project specific <br /> Pusuc HEALTH SERVICES Ew:N RALH TH Divis"houdy diarges associated with this project or advGy will be Wed to me or my business as identified on tus ban. <br /> I a W certify tltat I hav ra app �%AMe pedom>ed W be done in aozrdarlca with a0 SAN JOAaIn COI.P(TY Ordinance Codes,Sfarldenfs,STATE and <br /> FEDERAL laws. <br /> APP,KANT SNruuNaF DATE: <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER . cle OmNER AUiqugDAOENf <br /> aAPwcwrkrccas �' rifle <br /> AUTHORIZATION TO RELEASE INFORMATION.Whenappkable.L b)ae oroperatorof Ne property bcawd attie abate siteaddress.hereby audmitzs the releaseof <br /> any and as msultt geotechnical data w0or wATi mlentalf509 assess meR informadon Is to SAN Jokom COuNTY PLeUC HEALTH SERYIES Etwito meNTAL HEALTH O&-woN v soon <br /> as it is available and at DIe same 11me it R plovded Is me or my mprmanatim <br /> TYPE OF SERVICE REQUESTED: 7-11Q <br /> COMMENTS: <br /> 5 <br /> INSPECTOR'S SIGNATURE: CoKrRAcTosesSIIGNATURE: <br /> �/ Ate' <br /> APPROVED BY: Z Ew�LQyF_fr•. S DAM <br /> ASSIGNEDTO: VV EMPLOYEE#. `3; DATE: �( _t} <br /> A Date ServiCP Completed (if already completed): SERVICECODE:�)L30 -PIF- <br /> 17 <br /> Fee Amount: Amount Paid " Payment Date <br /> Payment Type Invoice A Check B Received By: <br />