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SE ME REQUEST <br /> Type of Business or Property FACILITY 10# SERVICE REQUEST# <br /> A5 "STA 1 , 00A UuKiJowrj 'tlat.('k,��G� IJ <br /> OWNERI OPERATOR BILM PARTY 0 <br /> FRLD AKZAD Ano MAPK YE.t�T <br /> FACILITY NAMEMA-Soo C F N iE t2 L L C <br /> $READDRESS 6U ^I�5 SU..NvmO.. M.G. c;F; <br /> ;C ll..N.n. Ury0•� Su ., <br /> Mailing Address (If Different from Site Address) <br /> 3 6 Nq t) <br /> CITY fa iV U t 1 t , CA ATE 0 <br /> PH0NE#1 em APN# LmDUSEAPPLICAT1oN# <br /> (yam 0300 U KNowN <br /> PHONE#2 Mo. SOSDTRtcr .; LOCATION!CODE , <br /> CONTRACTOR/SERVICEREQUESTOR <br /> REQUESTOR BttJJNG PARtt <br /> I EUF �1A ouh ST Feyr <br /> BUSINESS NAPE <br /> A. C PA i T G- P7o# G43 a4�9 �&T'W <br /> MAiLmAwme s <br /> (� 14 � TP,F. m 7 kD 7i 6.3 <br /> CITY i xc N STATE CA zP `166, D <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same, adhawiedga that all site andlor project specific <br /> PUBLIC HEALTH SERVICES ENVROaENTAL HEALTH OMSION houly charges associated with the pmiect or activity will be billed to me or my business as idenCfleo on the form. <br /> 1 also cedfy that I have prepared the application and that the work to be perforated wil be done in acCordance with as SAN JOAouN COUNTY Ordmance Codes,Standards,STATE and <br /> FEDERAL laws. J <br /> APFLicAi T SIGNATURE: DATE: 0 O tD <br /> PROPERTY!BUSINESS OWNER 0 OPERATOR I MANAGER ❑ OtHmAuTHOR®AGENT V aP- 01 NATO f� <br /> rAPRXAW b not lea Raiml)Arrr.prodayaudprizadwr to sip is roquklw Title <br /> AIUTHORVATIQN TO RELEASE INFORMATION:When applicable.1,the owner or operatord the property located at the above$ite address,hereby autwdm the release of <br /> any and all resuhs.geotechnical data ardor envimnmentaVsde assessment infarrh>atlon a!t e SAN JDAWw COUNTY Pumrc HEALTH SERVICES El soKwNTA-HEALTH DIVISION as soon <br /> as It is available and at the same thne it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ^ / <br /> COMMENTS: <br /> rF <br /> INSPECTOR'S SIGNATURE: 1, CONmACTI SIGNATURE: / <br /> APPROVED ey: , E!IPLOY--A: DATE: J QLD <br /> ASSIGNEDTO: L�� EMPLOYEE#: DATE / z <br /> Date Service Completed (M already completed): SwAmCoo P f E:. 03 <br /> Fee Amount Amount Paid Payment 4L6/60 <br /> ZG <br /> Payment Type I Invoice 0 Check# O Received By: y <br />