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'�.. SERVICE REQUEST --� <br /> Type of Business or Property FACILITY ID I: Ts, <br /> RVICE REQUEST R <br /> � n �vs � Y hL Sl Fcc ;l ♦y RZCO 3 <br /> OWNER OPERATOR SLUNG PARTY <br /> -c de , e, Lj <br /> FACIurY NAME <br /> l- A CKL, u- CO, V- <br /> SREADDRESS <br /> 7 5 Hiner D4 Strw)licca �/ TWA SWC! <br /> Mailing Address (if Different from Site Address) <br /> CITY STATE ZIP <br /> 9S2 S <br /> PHOHE#1 APNR LAND USE APPUCATIONY <br /> ( oq) 4 66 — ' '72-C 00 - 3Y vp - - 15 <br /> PHONE S2 eAT- SOS DISTRICT LOCATION E E- <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQtESTOR SLUNG PITY r <br /> ✓� � [t Cam i Sf <br /> BUSINEss NAYS PHONE# rII. <br /> e dty X,. f— os, — 41 Z7 <br /> MAa1NG AODREss FAX B <br /> 4I vs, � . �. Sv:4e 1.10 5' verb 927- 7C <br /> CTTY q JO Y4 STATE C ZIP S) 2 (] <br /> BILLING ACKNOWLEDGEMENT: I. the undersigned property Or business ovmar,operator or authorized agent of sans, admowledga Chat all site andlor Pmjact Specific <br /> PVBUC HEALTH SERVICES Erimc".FNTAL HEALTH Cmwti hourly durges assodated with COs Purled or attvq vn➢be tilled to ma or my business as iden6(rd on Otis forth <br /> I also ceroly that I have prepared this application arxl Cut the work to be Performed wd be done in aoxrdanoo with all SAN JOAa m COUNTY Qrdinenca Codes.Stenderds,STArE and <br /> FEDERAL laws. <br /> APPLr.MT SiGNATUDAM oy <br /> PROPERryl BllsetESS OwNEA 0 OPERATOR/MANAGER u OTHERAUn10RIZEDAOENr ❑ <br /> JrA w x:n 9*BL Pum pnofo(wthortatlon rosgo 4 rhp "d Till@ <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,L Ce awhwr or operator of Ow Property located at the atwre sit address,hereby audlalze dw relaam of <br /> any and all rest9m geotedmial data anllor erv:onrhwnlaVsim assoasrnem niumatim 0 If*SAN Jean COUNTY Plratx HEALTH SERviCEs EwFto afrA NEAL H DIVISION as soon <br /> as R Is available and at Che same time d is Provided Io me or my represeTptlre. <br /> T"PE OF SERv)CE REQUESTED: <br /> COMMENTS: <br /> Y -Q„ OP� _ �.A'�• SPu`M��N5E��4SION <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED By: Eun—cr'r.C: Q' I DATE: <br /> AssIGMID TO: EMPLOYEE$: ! DATE: 2�liU 'v— <br /> DateServiceCompleted-(dal dycompl ): SERVICE CODE: lib <br /> Fee Amount w Amount Paid Payment Date 9 a/D�— <br /> Payment Type Invoice# Check D Received By: ZyL <br /> �3 <br />