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�r <br /> 0 0 <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST:t <br /> .2 <br /> OWHERf OPERATOR BILLING PARTE 0 <br /> FACILITY NAME <br /> SrrFAooREsS1 <br /> 09 sv..c Non+4.t unction ` •� ' Trn� suer. <br /> Mailing Address (if Different from Site Address) <br /> Cay STATE ZIP <br /> EXT. APN# �3 oO f LANDUSEAPPLICAT)OR2 <br /> PHONE ff2 ems. SOS DLSTRtCY LOCATtoN Coon~ <br /> CONTRACTOR I SERVICE REQUESPOR <br /> REQUFSTOR BILLING PARTY <br /> BUSINESS NAME PROBIT# �i f EXT <br /> MAll1NG AooPms i FAX a <br /> Crrr 1 STATE ZIP �2If D <br /> i3lLl_ING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or autharcad agent of same,adwaledge that al[side and/or projed specific <br /> Pusuc HEALTH SFRvtCEs EtimcmA I4TAL HEALni Drwscm hourly dtarges associated wdh this project or attty*will be bided to me or my business as idenotied on ttus form. <br /> 1 also carWy that 1 have prepared this appkaWn and that the work to be perfanned rot be done in aomrdance wit all SArt JOAmm Comw Qrrtrasrrcn Codes,Standards.STATE and <br /> FEDERAL laws. <br /> APPLr.maSiGmTuRE: OAM �/O2- <br /> PROFFRTYIBUSINESSOWNM Q OFMATORIMANAGFR ❑ QSHERAtrI}lORl2EGAcE►TT GllllL �"XLGf�I .L�_ <br /> YAPPix'sw7:siWtm ftLLM praaf of Tru hW9"0W to UP)s neuirs Title <br /> iW-rHORWATIONTORgLEASE INFORMATION:When appimble.I,the uwrwroroperator d the property loCated at the above site address,hereby authorize Me reieese of <br /> any and all resWts.geote(ftkat data ar4W w4unmental/site.assessrnent Inf=atlon to the SAH Jmot)rr Comm Puaic HEALTH SERvtcES EwRoNmExTAL HEAL-m DMtSm as soon <br /> as it is atonable and at rise sante time it is provided to me or my representative, <br /> TYPE OF SERY)CE REQuF"TET}: F <br /> COMMENTS: ¢?-9. OZ . �,�r To ,4,*- CtAPZra cx/ T A14rS <br /> hCG (av Awor-T3 7w?-;g 1P rP113 C ov �-r s �—r�, f9� s p b�F- <br /> lit HGSz V- cw <br /> ti <br /> APSSAN 5 � � <br /> FPJ KR OH aLI"JF�UN7 Y <br /> V1por'!"RENTAL N,IA.(Il�vlLFS <br /> 1 11 fc!(;r <br /> INSPECTOR'S SIG TUR COMRACTOR'sSIGRATURE: <br /> APPROYED DAM <br /> AssaNmTo: Ewi oYEE#: DATE: <br /> Date Service Completed-(tf already completed): SFRYIGB Com TP[E-- <br /> Fee <br /> EEPee Amount Amount Paid / g © D Payment Date ft lD <br /> / , .� <br /> 3 Payment Type T/ Invoice# Check S �a� Received By: <br /> b6 mTk <br />