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SFRVY_F RFOt IF.ST <br />I •1110/[hto) *I[•ioIle, �iXT • � • <br />ri ESTOR BujNG PARTY ❑ <br />Typ of Business or Property c <br />FACILITY D <br />SERVICE REQUEST x <br />r <br />C �_ L6 <br />MArurIG AnoREM <br />1 /T <br />' <br />OWNER J OPERATOR BU MG PARTY ❑ <br />FACILITY MAME <br />�• � �� <br />6Cutti�J <br />VISL _ <br />CITY_ STA LP <br />SRE ADORESS <br />tr ' <br />`-= <br />DATE: <br />ELPWYEE#: 2 <br />DATE: <br />Mailing Address if Different fFom Sitp Addressl <br />StRaxcooe <br />CITY- STATE Zw <br />PHONE#1•' <br />-93 <br />APN # <br />LAmo USEAPPLICATION rY <br />#2 <br />BOS DIS = <br />LoCAtON CooF- <br />I •1110/[hto) *I[•ioIle, �iXT • � • <br />ri ESTOR BujNG PARTY ❑ <br />BUsmu NAL <br />NONE per. <br />RECEIVED <br />MArurIG AnoREM <br />Wy 7 200? <br />FAX lR <br />SAN JOAC}UIlV �:,'(I(�r, <br />PUBLIC HE4ClH SES v <br />F.WPONMFNTA! <br />CITY_ STA LP <br />BILLING ACKNOWLEDGEMENT. l the undersigned property or business owner, operator or authorirad agent of same, adnowkAgo that au Me andlor projod specific <br />Pueuc HEALTH SERvr-Es Emrotet+ AuaA. HE&TH DmscN howdy charges associated with this project or acilvidy wil be Wed W me army business as Iden 'Dried on Chis tont. <br />1 abo car* that I have prepared this application and that the work to be performed wil bo done in aa:ordance with all SAN Jasam COWlY Wine= Codes, Standards, STATE and <br />FEoem laws. <br />APPLrAHT SiGmTuftc DATE <br />PROPERTY IBUWiF aOWNER ❑ OPERATOR ItrW 4M ❑. 0MMAtmouEDAGENT ❑ <br />rMrururriana OwOLLM m%prod&mawtratlonros4akrr4 Tilt* <br />AUTHORIZATION TO RELEASE INFORMATION: When appkable. L the owner or operator of the property iocated at the above sib address• hereby audwrLm the rusreese of <br />any and al results, geotechnical data arW" assessment kftmadon lo the SAN JGk m COWTY Pum KE~uH SERYsms Elmrtom*)aA. HEALTH Omsm as soon <br />as a b available and at The same time it is provided b me or my mprosentallm <br />TYPE OF SERVICE REQUESTED: ' 1 j - i 4—ra� <br />COLLENIS: <br />APPROVED BY: S L <br />ASSIGNED TO: <br />Date Service Completed -(if already completed): <br />Fee Amount: <br />Payment Type Invoice # <br />PgyMEN`1 <br />RECEIVED <br />Wy 7 200? <br />SAN JOAC}UIlV �:,'(I(�r, <br />PUBLIC HE4ClH SES v <br />F.WPONMFNTA! <br />CONTRACTOR'S SIGNATURE: <br />`-= <br />DATE: <br />ELPWYEE#: 2 <br />DATE: <br />StRaxcooe <br />p M. <br />Amount Paid <br />Payment Date <br />7 <br />Check # v k <br />L <br />Received By: <br />