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r SERVICE REQUEST <br /> Type of Business or Property FACILITY!D# <br /> SERVICE REQUEST# <br /> OWNER/OPERATOR <br /> BILLING PAIPQ <br /> Factum NAME <br /> SITEADDRESS <br /> G?u 5 t KL'Ct(- 0C,/ <br /> 2P4014E#2 <br /> s (if Dffferen from Site Address) f .„xam. rte. <br /> swi.,r <br /> s / ti n- ^=�S7A7E�/'.-'L� ZIP <br /> APN# <br /> 1b©S- fi� Q ,DLnxo l7sE ArptkATION#Ev. BOS DISTRICT <br /> G•ii �- f LOCAT)6:CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REauI3TOR <br /> ` Q V V'f S l/G C. lisp BALAiGPARTY <br /> BUSINESS NAME Px0`N'EC#~ VV\ <br /> MAILING ADDRESS <br /> c s LxC U-4_ FAx# <br /> tr�Y <br /> STATE � ZR <br /> BILLING ACKNOWLEDGEMENT: t,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site andlor project specific <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL REALM DIVISION hourly charges associated with this projec{or activity will be billed to me army business as identified on this roan. <br /> I also certify that f have prepared this application and that the work to be performed will be done in accordance with al SAH JOA OUIN CouNrr Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. <br /> APPLICANT SIGNATURE: / r <br /> DATE: <br /> PROPERTY I BUSINESS OWNER OPERATOR I MMAGER Q OTNERAUTHoRZEDAGEN1 <br /> r' 1lAPP(X.WrisnorIl)p _M proof ofSuUroritaf}ontosignisrvquirnd� Tille <br /> C 3 ,�J lQ� �wneroroperator of the property located at the above site address,hereby authorize the release of <br /> J r"[ /a.3 sa6on to Use SAN JOA=N COUNTY PUCLIC HEALT11 SERvsCEs EwRONMENTAL HEALTH DmsION as soon <br /> f <br /> 3 - <br /> D8 -a(�� <br /> PA•(NyEf RECE'VE <br /> OCT <br /> �Lf7E SAN JpA0U1N COUNTY <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMEW�WI HFAI_TN DIVISION <br /> CONTRACTOR'S SIGNATURE: <br /> LOYEE#: �`L�j�. DATE: <br /> ILOYEE#: 1a� DATE: <br /> SERVICE CODE: I <br /> k .. : .�'�`� <br /> 17 f. �-D payment bate Gb L( a 0— <br /> Check 0 D 0 Received 8y: � <br />