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Type fo Bu ,S ness or Property <br />OWNER I OPERATOR V /� <br />�i. a 5� jJ lam[ <br />FACILITY NAME <br />SITE ADDRESS / 3� Nor pi xtion <br />Address (If Different from Site Address) <br />Mailing <br />SERVICE REQUEST <br />SERVICE REQUEST <br />FACILITY ID # <br />L16 '7' BILLING PARTY L <br />L- <br />�iJ � 1 � �lt1 ✓ `� � y � TYD� I $ui•J <br />APN# <br />PHONE #1 <br />s BOS DISTRICT <br />V6 <br />R <br />PHONE #2 <br />CONTRACTOR I SERVICE :REQUI <br />REOUESTOR L / %�G "l` <br />STATE ZIP <br />LAND USE APPLIC-KnO n <br />LOCATION CODE <br />BLtUNG PARt. <br />Ext. <br />PHONE# C i <br />BUSINESS NAME <br />v i,� / ��0/ly/'l�i`✓ / z FAX# <br />frtAR1NG ADDRESS STATE / ZIP <br />r 1C L� _r7 <br />[� e that all site andlor project sF <br />CITY lZ for or authorized agent of same, <br />acknowledge <br />e or business owner, opt or aCivit) will be billed to me or my business as identfied on this forth. <br />1 the undersigned property ted wdh this pro) <br />JoAotnN COUNTY Ordinance Codes Standards, S A E and <br />BILLING ACKNOWLEDGEMENNTAL HEALTH DMSION hourly charges asspoa <br />PURI 1C HEALTH SECEs ENvIRCtr wry be done in accordance with aa <br />SAN <br />I also certify that I have Prepared �� application and that the work to be performed <br />_� DATE: /l <br />FEDERAL IaWs. , ,• /� <br />APPUCANTSIGNATURE: (�Z/" G �ERAUTHORIL'w r Title <br />OPERATOR 11NWAGER of wthori '- M sign cs r"V <br />� tl Aaax� � � � R.�_ proof authorize the release of <br />PROPERTY i BUSINESS OWNE r of the property located at the above site address. he HEALTH DIVISION as �n <br />AL <br />AUTN0RZA11ON TO RELEASE INFORMATION: When applicable, I. the owner or open COUNTY PUBLIC HEALTH SERVICES ENVIRONMENT <br />any and a� results. geotechnical data andlor errvironmenmVsite representative. atiat m the JDAouIN / <br />as it is available and at the same trine d provided t0 me or my P <br />TYPE OF SERVICE REQUESTED- <br />CoMMENTS: <br />TUBE: <br />APPROVED BY: <br />ASSIGNED T0: <br />Completed (if already completed): <br />Date Service <br />Fee Amount: <br />7—:::Invoice # <br />Payment Type <br />I DnTF' <br />DATE: <br />IEMPLOYEE <br />SERVICE CODE <br />I payment Date <br />Amount Paid <br />I Check # <br />-PIE: I <br />—; <br />Received 8y: —J <br />JAN .0 2 2003 <br />ENVIRONMENT HEALTH <br />PERMIT; SERVICES <br />