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SERVICE REQUEST <br /> Type of Business or Property FACILITY IG# SERVICE RE 44T:� <br /> Cs L ,,�t� FA 0003 "7o� <br /> OWHER I OPERATOR BLLNG PARTY❑ <br /> ti iGt <br /> FACILITY NAME <br /> zf�2u D A <br /> SITE ADDRESS �k ST / 7-4 <br /> J _ <br /> Mailing Address (if Different IT=Site Address) <br /> STATE ZLP <br /> %J.5 " <br /> PHONE#1 W- <br /> APN# LAND U5EAPPLICATION9 <br /> PHONE#2 �• SOS Dsrwcr LOGTION CODE. <br /> CONTRACTOR I SERVICE REQUESTOR <br /> REQUESTOR SLUNG PARTY❑ <br /> BUSINESS NAmE PHONE# Cs<- <br /> 5A(A)W 11v . <br /> MAtuNG ADDRESS FAX# <br /> nye <br /> Crry �J e2�o ATEA 3 g� <br /> BILLING ACKNOWLEDGEMENT: I. me undersigned property or business owner,operator or autharnd agent of sane, adavwfedge timet all site ardor project speak <br /> Puauc HEALTH SERVICES ETPRC.%F AL HEALTH OrvisrA hourly dmarges associated will;this project or adNily will be bled to me army business as idended on tlmis form <br /> I also certily that I have prepamt s application and mat me m be performed will be done in aanrdance with all Sur JOAaAN CouNTY Ordinance Codes,Standards,STATE aM <br /> FEDERAL Iaws. ATG <br /> APPLrCAw SIGNATuNE; /1 L\ /�C t.-c-Z. . - DATE: <br /> PROPERTY I BUSa"OWNER ❑ CPERATORIMNIAGER ❑ GreMAWHOR EDAGEMT .Q ('o AJTI2Ae 76/C <br /> YAPn.Gwrerc/tlw Rrrro TTII* <br /> 4AUTHORIZATION TO RELEASE INFORMATION:When appkable,L me owner orcpwawT of me property booed at me above site address,hereby and afm me release of <br /> any and all rewlts,geotechnical data w0or ertviorutmcrtaVsite assessment inlonnetfon to do SAH JOAQuw CGurnY Puauc HEALTH SERVICES EmwoNwwr&HExTH ONts"as soon <br /> as if Ls availabie and at Cme same time it is provided to or my representative. <br /> TYPE of SEiv)cE REQUESTED: <br /> COMMENTS: �J I <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY. C �. /L Es1PtQYw'rt. Ctq ro-� DATE !i zoo <br /> AssrGHa To: m I I - ErPLQYEEtkS DATE Y�IL4_ <br /> Date Service Completed (rf already completed): SERVICE CODE: / LJ PIE- <br /> Fee <br /> IELFee Amount Z, Amount Paid Payment Date <br /> Payment Type Invoice# Check# Received By: <br /> 0 -3-t <br />