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SERVICE R&QUEST <br /> i+pe of Business or Property FACILITY 10# SERVtCE RE12UEST <br /> Owmelt I OPERATOR <br /> OLLM Pa tz t 0 <br /> 1 <br /> FAcli.TtY tNAmc- -- , <br /> SITEAWRESS �'Z�_l <br /> !Nailing Address (if Different from Site Address) <br /> saw: <br /> STATE ZSP <br /> J ,* ` gxr. A ft LAND Usr APn cATYJN - --- <br /> PHONE#2 LAr• BOS DISTRxT l LOCAWN CODE. <br /> CONTRACTOR/SEIRV;CE REQUESTOR <br /> T _ <br /> liEClr)EST iR Blum PARTY 0 <br /> BUSINESS NAA+ PHONE# � tn. <br /> DR <br /> ADESS `� G —7 FAX9 <br /> yin <br /> $TATE r- ZIP <br /> t y <br /> E3lLLiI G A KNOWLI i3Gl ?J1ENT; L the rtndL a'red property of business awreT,operator or authotizosi agt nt ei sanro,awe Yaat aA s4a andlor t ic <br /> Post lc HEAt,T}t SERV res ENw G u taTAt i Al nr OlvtSl�rt tloltrty c large;a=ciated withtis ptojee,or act3vitp wit be biped to MOW my business as WwWwd on Ns Tom <br /> !ai:rr unity li la!I have pn parma this app' that, to bio:Pert Twd mil to&!Ie in a=fdar,rr Witt,ap SM JOn"COUNTY Ord, »rrce CW s.Stoma STATE and <br /> FExRAL Laws. <br /> APPLXANT SX-RA-'URC, bATi <br /> PAoPERry,'BuSwEss ERWORftAANACER 0 OiHERAUT�ACw Lj <br /> NAw.,,cwr,x mt trio D <br /> $33M_.p " 1�d JvZo rxAbn Try sign is requited Title <br /> any a i anjesu t ,g Tt,REL EASE r4kr htA7t_N.When aq*able,t,the owner V opaTator Tri the prWdy�ocated at L".e abave site address,hereby zxmrun 0*rebase d <br /> any anzl an result r,gevlcchnrat data arttliar errlilw mentaysile asses=wnt irttor„laton to ala Srsi JOtwtm CWN7r Ptak W-*L74 SERvICE:ENVtxtON►Xtr AL kir TR 1k VZ04 as siren <br /> aJ if is evaiiab anis at the ear„e t e iti5 P+o+r slcG to Tae or rr!re;rtsemaiive. <br /> TYPE a"r SERME REQUESTED: <br /> COMMENTS: <br /> � <br /> A, �Cl'M E NT <br /> RECEEIVED <br /> MAR 16 2001 <br /> INSPECTORS SIGNATURE: _ <br /> ` � �Yr ✓C <br /> t� <br /> SAN 10AWIN C)UNTY <br /> PI)81 C HEALD,S[,A ICF_5CaNt <br /> CONTRACTOR'S SiHATIRE: <br /> -' <br /> EMPLOYEE DAT£: <br /> AsstGNEoio: El1PLoTEE DATE: <br /> _Completed <br /> ---� <br /> (it air&4y COmpleted): , 0 , SEAVrE CODE: (�� � -[PIE <br /> �r <br /> Fee Amz+lni Amount Paid ' ,, _ Payment DateJ <br /> 1 Pay;ientType Invoice ✓j 1(' � <br /> t _ ChrciC# i Received by: <br />