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r SERVICE REQUEST <br /> Tyype of Business or Prop ert FAIgKX YQ10 9 SERVICE REQUEST C <br /> 1 <br /> OWNER/qPEPATOA� BILLING PARrf <br /> J= J41r LD113,4A 1,4 L\, c--. <br /> FAC"" <br /> SOE/AC�OlRIESS <br /> ..ilA <br /> WIN Addrxas (It Different from Site Address) <br /> C:r <br /> STATE ZIP <br /> P.nHE 9 — [n. APNR IMOUSEAPPUCATgNZ <br /> LPHONE12 _ a an BOS DISTRICT LOCATIONC00E <br /> CONTRACTOR/SERVICEREOUESTOR <br /> REou-_OR Qll�,LMRTY❑iJ._tA1M � � VXFCCrrr R 11 ' - STATE , <br /> UI ._L•.S..Y•l-���� _ <br /> 21LLRlG ACHNOWLEDGEMEM: I, the wdasgnod pmparry or business awner,operator or aulhorfaad agent of Tama, adwaeledge tlut all ads and/or Pitied specAc <br /> PU JIjC HE M SCRVr Z-.EMRCM e1M HEALnI OMSMWudy charges assactated win Its prorct or adMty wo M billed m me or my business as dendled minks lams <br /> I a:+.,'smry nal 1 bavr.;,r•pamd nu apOn%sbon and tRn nc work m M;perbrmed w:0 bo dono in aavNance wilt)atl S.w JOAaw Courm'ONnanro Codas.SfarHaNt.Surf and <br /> TrnFi• ITVR ' <br /> A.aUr.A.Axr Sr.xArVUF' d�/L� / l� DATE: <br /> Px�;PE.irrl DUSWESS O'MrTil D CPERUCFIl/snrr#n 2OnrFA AUnaNZEn ACFNr ❑ <br /> YM.Finrcrur as Bar nr.PAary paddwdwtrarM bsipnb..quid Till. <br /> AtiTHOR V-ATION TO RELEASE INFORMATION:When appfirabb,L the owns ar aperamr of Ins pmperty located of Ne abavo side address.hereby Authdfm nn mlaxie of <br /> An,and ah msulb,declerJ�nicTl dam anJbr emrionmenOsysde aveUment inlamubon As To SN JOACuw COUNTY PUBLIC HEALM SERVICES Et(MOMMEM i HE&1. OnASION as soon <br /> i i.avar'abir:and at me Samn 7me It c pnrvFlM m me or my reproemakno. <br /> TYPE OF SFww..E REouESTFO: <br /> CCRHE+tS a�l r-B' <br /> 'PAYiVlcEN", <br /> �ECrnrEr <br /> ; P _>t ZUj) 1 <br /> SAN J0vwUIN GOON Y <br /> PUBLICH AIJI4 SF RIHCF <br /> FNVIRONMFNip,I 11[411H H4..n,IDfl <br /> t <br /> INSPECTOR'S SIGNATURE: CONTPAGTOII'S SIGNATURE: <br /> C,+PROVED ITT: EurLOr--P: DATE:' <br /> ASSMNEDTO: Eao•LorEE t: �Q 8 DATE: <br /> I <br /> Date Service Completed (it already corn ): SERVICE CGoP_ Q PIE 3 <br /> Fee Amount °�- Amaunl Paid ��a _dQ Payment Date 9 a O/ <br /> i <br /> Payment Type. ✓ Invoice0 37,25 Received By: V <br /> .a <br />