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SERVICE REQUEST <br /> Type of Buslnes//s or Property FACILITY ID k SERVICE REQUEST i <br /> �t?)d e ��— 2 2 .� <br /> OWNERIOPERA/TTOO'R� BLLUNG PARTY <br /> FAca.nY NAME <br /> SREADORESS , <br /> �� a aa.aNvror E . Sty c c@! 1 z T� s:.e <br /> Mailing Address cif Different from Site Address) <br /> CrrT 1 e m n t s STATEZIP <br /> PHONES1 APNA LAND USEAPPLNCATmu0 <br /> PHONE R2 e+T• HOS Dtst= LOcAwN Co0E <br /> CONTRACTOR!SERVICE REQUESTOR <br /> REODESTOR n C_ BILLING PARTY❑ ` <br /> BUSINESS NAMEPNONEII �� Nita. Nn <br /> 4 Gfd r. 3&q �V <br /> MAILING ADDRESS/ // / J FAzf /� <br /> Cay %U � LT // ^�� STATE Z8 `5 <br /> BILLING ACKNOWLEDGEMENT:L the undersigned property of bosin#ss own@r,opn lor or authorized agent of same,adnorledge Nat as site andlor project spectc <br /> PueLIC HEALTH SERVICES ENvRC+o rENta HEALTH Omsm houitf dwges assoaated with ba pmjertoraat d w0 be Beed 0 me or my business as idetwW on en form <br /> I atso Certlly that I have pm application 1hXe lo be performed will ho done in a=darrm with all SAN JOAaM CotMTT Ordinance Codas.Slandsrds,STATE and <br /> � FEDERAL taws. / �) <br /> APPLICAIR SIGNATURE: L (TATE: ( G (/ C. <br /> PROPERTYI&MEss O OPERATORIMAwfR ❑ OnrnMJnaw=AcENr ❑ �. <br /> 1APPcwrsnafa■R.,n-n.arr Proa(orav(AaWtlan toslmh Mused rill# <br /> AUTHORIZATION TO RELEASE INFORMATION:When app6cado,LOW umrnar a operator d Na prvpany located al Ne above aft@ addniss,befeby audmalTa do rebased <br /> any and all mstdM geatectmk al data arWor enviarm>entaYsda asstl=mCnt imfortnetM lo ON SAN JOAOLN COUNTY PURR HEALTH SEROCES E IROWNpGAL HFALTN OMSIM as soon <br /> as a is mdable and at Ne same tine R is piwided lo me or Ire mpresatmtlm <br /> TYPE OF SERVICE REoUESTED: <br /> CONYEHR: �,/ <br /> '4 NT": .e /y Jl y 2 r l�f( r� / Q J�D �47 / 6 . TLip Si <br /> p2�.Q s r2 e t�yr oar Y �� s r0 �� RF i <br /> rzCLI)g� d /Ln tP V), 7-11s�y� ,, 07,Q � o� rvr��.. . bar;-; ,T <br /> � y 5 ens 'T`e.'' vim- C�--e1� Q�' �' ,! Ju LTN NE <br /> 70 S@NV. �P1pd�yTo+. HF I PAA <br /> T� .TUVF- b � �7URE: Gam! <br /> i INSPE�fOR S NATURE CONTRACTORS SIGNATURE: <br /> APPROVEo9T: l'f F EWRaY`— : r DATE — Jl <br /> tv <br /> ASSIGNtD TO: ��_( l C Qr EYPLOTEEk T0.5 DATE C// �rl <br /> Date Service Completed (tf already wmpte ETtYNCECooE: 'P!'E 6 <br /> Fee Amount Amount Paid Payment Date <br /> Payment Type InvoicelF Check it j 3 Received By: <br />