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SERVICE REQUEST <br /> TT 0f r3 or Property FACILITY ID# SERVICE REQUEST# C <br /> �T <br /> !Oa _ <br /> Balm m PAM TJ <br /> 0A CQ <br /> Str>< } <br /> Sawa RUMWS <br /> VIA <br /> . Ty" srr.ra <br /> Mailing Addrm (If Different from Site Address) <br /> Crry Lo PSOM 1HS c� <br /> exr. APN# LAND UsEAart.lu►non# <br /> ( 2)73- (�,I(U <br /> PT3oNfe#2 Fez BOS DisrwcT s. LOCAMN CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> Rr<auEsroR <br /> PHI PAPUY Q <br /> ce 1# t� <br /> Busmus NAxE O g ( 10 <br /> 1MAanro Aooass FAz# <br /> cm SUM A ZIP <br /> dk <br /> ¢( t �CMOWLEDGEME�NT:L du uadassi9nad PmPerty or hmn Om owner,OPw=or uuhorind Worn of"aw adaiawledge Cyst Mandfor pa(edapt <br /> Ptrauc HE&TM Setv n E NF4N,�AL HEALTH Dvn*m W*druyes assodalad with tbb prgeaa acuity wl be biW brae or my baalnsss as'' -0 'On ft foci <br /> 1 ON car*That I Have preputd thm appkatlon ud dui die work m be Pertrrnnsd N be der in auardunoa wqh ad SAH.1oA m Cowry Or&wm Codes,Sh n*nfa,BA"Al d <br /> FEDUkAL laws. <br /> AITT3iC.IrATUAL l 2C IM ZC.;o,.DATC <br /> KJGWa Q <br /> P} Mry 18U8awm OWNS ❑ OPERATOR I MANAGER Q OnfA Avrr u=AGENT 0 Title <br /> KAPKrMr k rcf tw w 1.c PMtY yrodaf&AhWftWka to sips is nqukW <br /> dQ 71109 sTION TO RELEASE LNFORMATiON:When a�abb.L tre wmw or operatord to Prop"fasted at T*atwrs sda address,ttwtrj autllOrttJ/tb147>wt ROt <br /> am and d results ari <br /> "otechr�al dear ll savkwmWWh'ft sssessrnart irft7atfan b the SA+c JWarN COtxtTY PMA t TfALTH SERv�CEs Elrvrtota6tTN FiFItAt DNT RiE#Ot7es <br /> as K is ava8abie and at the same tlrne it Is provided to rns or my rapras&-aN - <br /> TYra OF SErroa REWE=: 1 h C <br /> bave=*$Sn "TUR : CoxnthcroR's Sf6xArm <br /> or EtwLOY�t. DATE <br /> As"Um To: 3 S 8`D 3 Z� DATE <br /> Data Service Completed (it ahady compie&* SQtvMCoae -P fE: <br /> Foe Amu Ped � �— Payment Date lin In <br /> Prymoat TIPe Chccii 0 Riaelved By c ,, <br />