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07/24/2002 16: 31 2094683433 <br /> FIFTH FLOOR <br /> Hut Ci 7 <br /> Swr*VE RECUCST <br /> Type of Business or Property FACILITY ID x SERVICE REQUEST I <br /> ori i f4 c7 <br /> OWNER I OPERATOR 6`�kG PArrtY <br /> C3 P, w EST �a <br /> FACRJTYNAME Ar / ,^ <br /> SRE ADDRESS ��-ZS <br /> 70�.c Aturl�oa OtnnoA ► lSAG fJL-, y�Nr,w 1�'w iLbi <br /> Mailing Address (If Difterem from Site Address) <br /> 4 c <br /> Cm KI:� cc C)i MT p <br /> LA PIC'-L-H p STATE Z, <br /> CA o!0 2 <br /> � 3 <br /> PNONE ft1 prT• <br /> pv 20-1 -o 14-� <br /> LAND USE AvPt9GaTTDNg <br /> PNONE 02DRS�sTRCr LDGiTIDN CADS <br /> t 0 - QQ <br /> CONTRACTOR/BERM REOUESTOR <br /> REI' ESTOR <br /> Slim PARTY 0 <br /> BUSINESS NAME <br /> PwoNEt1 br. <br /> MArtuio AcoR gss FAx x <br /> Cm <br /> STATE ZIP <br /> BILLING ACK NOWLEOG hr I.the unaemsyned proParty or bvsineas owner,o <br /> PusUc HEALTH SE s Er+vaoN�HTAI HEALT)1 QnnS+ON pwU"or wAork w agent of same.bckw wedge Cwt ail site ard/w project neck <br /> chm"assoclaeed wkh Oro Mod or lovily wAV be billed W me or my business as 4eridCd on thb form. <br /> I a130 WVY Ont I have prepared C+a eppfi 3b-and that the wont b be Perbrrried w l be,00ne in wltT aY 5AN JOAgUw Courmr Drdinerrce Coecs Standards.STATE and <br /> FEDERAL laws. <br /> AYY{,yCANr SIGW1TitRE: -r Q � •F.J DATE: ! -2'57 -t�Z <br /> PROPFATY I BUSINESS OWNER Cl OPGUMR I 7=&n. <br /> lAurrCIUM AGENT 0_/�/T c G/r'rV T' <br /> it AUTHOR ILATIONTORELEASEINFORMATTOff;Whwt �� avahar�Gerrraabreoal.e rltre <br /> eppikabf Thsltoro(the PfcPery toasted aT4ee above cda Address,hereby aut)aM Cie rejewA of <br /> any and ail rssuitr gtol9Ohnigl daa tfndla anv+ronmennysms 8a Inlormatlon b CMG SAM JCMMWCOUMrY PUauC HFxTm Sc wcEs E"ROMMCOAL HEALTH DMS10N as soon <br /> as <br /> it's avaitahk end at e+e saav One d is Pmided b me or my reprCVenbAue <br /> TYPE Or SERvyCE REt7VESTetx <br /> CAYMEMS: <br /> INsPfmg'S SiGNA1URE: <br /> AvpnovEO Ery: ^-*TWACrOR's S*MArURr <br /> IISSIGNFD Tb: EVPL-:—f—, DATE: <br /> FJIpLaym DATE: <br /> Gate Service GomPloted (i(already eompleCed)• <br /> Fee Amount Amount S"VICE C40C DAmount Paid <br /> Payment Type �Y"MMt pate <br /> invoict?B C—hZ S11 <br /> Received 8y: <br />