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SERVICE REOUEST <br /> Typeoof Business o�rr S <br /> Property FACILITY ID# SERVICE REQUEST» <br /> OWNER I OPERATOR` 8 GPS❑ <br /> i35/ OII-) OF THE 6P,7p fy �A2D CsFURC <br /> FACIUry NAME <br /> MME <br /> SIIEAooREss <br /> ser N. TYv. Sw.r <br /> Mailing Address (If Different from Site AddreSsl <br /> CITY <br /> rgr- m-- eAp STATE zu, y�z3i <br /> PHONE 91 Exr. APN# LANo USEAPPUCATION# <br /> ( ) 1113 - 0 --3/ - a ,- 7 <br /> PHONE#2 ear. BOS OLsrRa-T L ocATIQN CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REOUFS'TOR BRRJNc PARTY <br /> DON Gf�C-s/v� <br /> BUSINESS NAME <br /> PHONE# tar. <br /> \,IAAF- do t2ESa Fr 6G8- 14 o3 <br /> MAILING ADOREsS <br /> PO, 00K 7-74 FAX �vb8 Z5�jpi <br /> CRY 9 LC)GK STATE ZIP <br /> BILLING ACKNOWLEDGEMENT: I, Ne WA=gned property or business owner,opualor or authoTvad agent of same, acloawbdgo trot all site andlor pmjoct spedfic <br /> PUBLIC HEALTH SERVICES EwscN--NTAI.HEALTH DrnwN hotnty dtatgm aswciaWd with this pmpa a aUNily Wig be bard m me or my business W idmefed W the Iorm <br /> I also artily that I have pmpamd Nis a tin and that rk m be pedomr:d ti be done n ao=dance wM aS N JOACARW CCAwiY DRlule40e Codes.Slandand STATE and <br /> FEDERAL laws. <br /> APPLICANT&&NATURE: 1 DATE: <br /> PROPERTY I BUSINESS OWNER ❑ OPERATOR/MANAGER OnµAAUTI"UM1AGEHT �T <br /> YMftl Tsnofftg MGPMn.pno/olan1wiucbn w zspob^Prna Till* <br /> AUTHORIZATION TO RELEASE INFORMATION:When aPPfic le,L Me awaw or operator of Ne Prop"bated at the above site address.hereby auanto,the rola of <br /> any and all results,geotec ni al data arallor enviaunentallsde assessment infmniWon to me SAN JcAQuN COuHTY Puaic HEwN SERVICES ENVIROW ENTAL HEALTH DmsloN a soon <br /> as ft Is avaMbb and at tl a same thne it is prorided to me or my mpn=ntallm <br /> TYPE OF SERVICE R iouESTID: <br /> Th. T /N( O/L Su /TfI B/L/ / /,=S b1,r-kl <br /> COMMENTS: <br /> �AocrvadA PAYMEiN <br /> jfwq C,,,,.a4 p RECEIVED <br /> n <br /> INSPECTOR'S SIGHATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY: //�ja! EsrPLaYE_P. (�' IS / DATE: <br /> AsSnNM TO: L/ a EMPLOYEE#. 12 DATE: <br /> Date Service Completed Crf already completed): SENvlcF CODE: S'2s "PIE: Z(o d z <br /> Fee AmountS� Amount Pa d Payment Date <br /> Payment Type J Invoice It Check# Received By-, <br />