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n <br /> SERVICE REQUEST <br /> Type of Business or Property :I; FACT IIY ID S!_RVICi:(it:QUI�ST <br /> • �I' l i li i ��J <br /> OWNER/OPERATOR , <br /> ;I BILLING PARTY a <br /> FACILrrY NAME <br /> y I II <br /> SITE ADDRESS 74/J it I��/� ' LJr�= �4� <br /> itr..t8wuor Wr�cdnq Su.aHwn T Pt sw41 <br /> Ma(ling Address (If Different(ram Sitd:Alddressl <br /> I <br /> Cii STAFF ..Zip <br /> rrY <br /> Lo, 'i II i, -1 <br /> tiHON#1 Est. A� ---' LANaUnAPPLiGAlto" .. <br /> i <br /> PRanE fat :I en. ;j HOS 13tsTTrtcT LocATlory CapE <br /> ii CONT CTOR f SERVICE REQUESTOR <br /> REQUESTOR BILLUit}PARTY❑ <br /> BUSINESS N"E l l PNQNE� <br /> htaiunG ADDREss �i FAX fa <br /> l iif°;tom. <br /> Cm !; STATE ZIP ,r�_�n 1 <br /> _Cr - "I <br /> BILLING ACKNOWLEDGBIdfrNT: I.the tjpdersigned ropelrty:br puslRi s4 Qwner,opgTator or autllorizaci agent of squlo.aamowledge MI all silo"or proled Speft <br /> PUBLIC HEV.TH SERvrCEs ENv1Ro"KTAL HFAtH DIVISION tllfur►y far§ essooiated wM this project or acth5y#4 ba Ped 0 RIQ or my business as identified on W3 form. <br /> also tartly Ilial I have prepared this appllcatorl and thal It�waik to be,perl vrta be do"41 Scgordanc9 VwM all SAN&koI CONTY Ordmante Codes.Standards,STAT€d � <br /> FEDERAL IawS. <br /> APKXANT SIGNATURE: t��- '� it I; DATEo� J <br /> PROPERTY/BUSINESS OMER CI OPERAT6R I M 1} D OTKER AUPIORIMO AG&fT � <br /> I k7IorauthOMAdorf N r b �4 rillsArPrYrfrT,rpt (�1.T�kP.arr.✓� rWl .I99" <br /> AUTHORtZATION TO RELEASE INFO 0 :wii�tn adp Wg G m ormer or operalor of tre propsrty located al the abavq gfte addiesq,hereby audnorize ma releap@ 41t <br /> any and all reruns,911 1)data arldlor enliirurlmentaVstia assessment Inf rnatian to the SM JOAOI COI PUBUC HMTH SERVICES E PIROriMEHTAt,HEALTH Orvlsiotl a;400 <br /> as U 19 available and at the same time U Is provided to me or C(ry reesntdv@. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: � iI <br /> ,PP>ef?5:'95�Far7`_ <br /> i' MAR - 91999 <br /> ii $Aid JI:IL'QUIIV 1_JII <br /> PUBLfC HEAIJ H SEAVjCE <br /> I; it EIiVIRONNIENTALHEALTH❑1UISIOr'd <br /> INSPECTOR'S SIGNATURE: � ! I CONTR=QR'S SIGNATURE.' <br /> APPROVED BY: it Ei PLOTF.E : � / DATE: '' <br /> ASSIGNED TO: E PLOTU#: 7' DATE: 3 �r <br /> Date Service Completed (If already ornp,eledh Eg=g ODE. P I B: <br /> Fee Amount: �.(9 i'ATR4ur11 P�Id b P'aymenl Date 3 cJ rII;r <br /> Payment Type olce <br /> IRv & ii '1 Ctlec�# RecpiY@d BY:_ <br /> i <br />