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VV/LY/LVVV 1L. VJ LV JJJ1Vf YJ N'I-.ILI\LVV J��LLL <br />06-22-18 12:14 PON-`-T`CONSTF. ' y„.�H1.203.547 9310 rb� 2 <br />SERVICE REQUEST <br />F—ja Q <br />7-678 P02/02 U-218 <br />T.vpa of Btesktat/ to Property <br />FACILITY ID M <br />RKautsToie� � ` . 1 <br />SERVICE REQUEST S <br />&49=3wwe� k 5 ocj� �vv:, <br />PHOM / 1,,. <br />D s41 31� <br />Hamor `4p <br />DArl; (p IOU <br />OM 91t I O PATO I I Ca. e t� b� <br />�8 l o r <br />C ,� n �1�,,2� <br />FAM1rr li&W W <br />foo Shca T06 rY1Q.l <br />DATE�4 (J Y <br />ahe-f <br />SERrictrCoot: <br />"WW <br />NW Amount <br />NW <br />W0 1D0 <br />Payment Data 30 c <br />PtrylromType ✓ <br />Invoice tl <br />NILT <br />Check if S7� <br />Reroiwd By <br />MCC or MALmo ADM $$ (if Dif wwd from $ib Address) <br />Harr <br />(may <br />8/ATE ZAP <br />Phu In �T' APN •� ` <br />no1+l Rte- 3�d14 �- /S, <br />two USE APPLICATION i �- <br />14th R <br />l 1 <br />603 olaTalcT t-oeAna+ Cooe <br />rnTvvvArTnU / CFRVIC'E REOUESTOR <br />1, the undersigfsd property or buginess owner. operator or surnunzou artist uj untuc, <br />adMaWledge ffig aU site and/or project 3pcclfic lENVIR0,NNEN'TAL HEALTH DEPARTWN't hourly charges associated with this piojw of <br />W tvity will be baw to uw or M buaioew as identified at this form. <br />I also cam* taint I bave prepared this application and that the work to ba performed will be done in accordance with all SAN 10AQl;na <br />CoLxTy Ordinance Codes, Stand dT, STATE and I'm laws. <br />Ar>U�'S SIGN: DATE! � 2 3 0 � <br />iROPOTY I BLURS” OWM0 � OfeNATOA / MANAGE OTHER AUTNORILFP 4GYNT,13 <br />ljAPPzj"NT is no, she Bn�tNO P�2n pre®jojammort-„alion so sign is req+urtd TWO <br />&MOWAT19p! 19 V: When applicablc, L, the owner or operator of the property located et the <br />above dte &d&03, bemby wthorize the Toloaso of any and all results, geottchnical data and/or en%'ironnun(sVsitc askessuxnt <br />in�oa to the SAN 1oAQuN Cowry E:NIViRONMENTAL HEALTH DEPARTMENT a9 boon at it is available and at the same tune it is <br />provided to as or my represeatative,�t�l t - <br />n <br />rft OF Guru” REWESTED: Lts-7- <br />13�J <br />RKautsToie� � ` . 1 <br />cr�K t+ e�L�Nn taaaR�as <br />&49=3wwe� k 5 ocj� �vv:, <br />PHOM / 1,,. <br />D s41 31� <br />Hamor `4p <br />DArl; (p IOU <br />Fa04 ALAI 61'3-- <br />�y <br />TA T <br />1, the undersigfsd property or buginess owner. operator or surnunzou artist uj untuc, <br />adMaWledge ffig aU site and/or project 3pcclfic lENVIR0,NNEN'TAL HEALTH DEPARTWN't hourly charges associated with this piojw of <br />W tvity will be baw to uw or M buaioew as identified at this form. <br />I also cam* taint I bave prepared this application and that the work to ba performed will be done in accordance with all SAN 10AQl;na <br />CoLxTy Ordinance Codes, Stand dT, STATE and I'm laws. <br />Ar>U�'S SIGN: DATE! � 2 3 0 � <br />iROPOTY I BLURS” OWM0 � OfeNATOA / MANAGE OTHER AUTNORILFP 4GYNT,13 <br />ljAPPzj"NT is no, she Bn�tNO P�2n pre®jojammort-„alion so sign is req+urtd TWO <br />&MOWAT19p! 19 V: When applicablc, L, the owner or operator of the property located et the <br />above dte &d&03, bemby wthorize the Toloaso of any and all results, geottchnical data and/or en%'ironnun(sVsitc askessuxnt <br />in�oa to the SAN 1oAQuN Cowry E:NIViRONMENTAL HEALTH DEPARTMENT a9 boon at it is available and at the same tune it is <br />provided to as or my represeatative,�t�l t - <br />n <br />rft OF Guru” REWESTED: Lts-7- <br />comm rm <br />SUN 0 2008 <br />JOAO�tN COONTY <br />5A ErNIFiONMETMENT <br />HEALTH DEPAR <br />ACCV70 By: b c— I �-) <br />EMPLOYEE 9:r 3 L% <br />DArl; (p IOU <br />Aiul"IMTo:/ C <br />Lj _ <br />EN/LOYE10: ( c� <br />DATE�4 (J Y <br />pttrla 6"ce Compbted (N airv*dy "rnP19*d): <br />SERrictrCoot: <br />PIFs: -2— <br />NW Amount <br />NW <br />Amount PsId a <br />Payment Data 30 c <br />PtrylromType ✓ <br />Invoice tl <br />Check if S7� <br />Reroiwd By <br />EIS 46-02-025 SR FORM (Golden Rod) <br />FM-VMED I WI7rj= <br />