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SERVICE REQUEST <br /> FRATO <br /> s or Property FACILITY ID O SERVIICE REQUEST A <br /> RR BILLING PAp,IY O <br /> FACL;rY NAME <br /> SITEADDRESS <br /> IJ,)- 1.;�StirtMr@!r prM@n Y G{, 1'A.S9 SbMa�mn T r AAre <br /> Milling Address IV DiBereat from Site Addressi <br /> CITY STATE MENT <br /> RECEIVED <br /> pwmf.Ri SIT. APNO LAND USE APPi1CATY.IN9 <br /> ( ) I I FEB�1�5�2001 <br /> PHONE f2 d- BOS:DISTRICT SRTTJFSALHIIN COUNTY <br /> PU c <br /> CONTRACTOR I SERVICE REQUESTOR HIA&TH OMSION <br /> REOIIESTOIt BILLING PARTY❑ <br /> (l r✓ u It �c r <br /> BUSINESS W W E ,�/� , <br /> Pmts x sn• <br /> 1 ► t \ S t'1—f— 5e r Vl Gz— <br /> MAulo Avows FAX R <br /> O ✓.3 S <br /> CRT m vi G .735, STATE ZP <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business omw,operator or authorized agent of same.3d:mw1*c hal Al site andior project spec c <br /> PUNL HEALTH SFAWFS ENVRatMFNTN,HFALTH DMS%IN houdy dwrges ausodated with:his project or actMty vel be bled to me a my business as Identified on Ws form <br /> I also cerEly hat I have prepared this appkabon and that the work TO be periomied w7 be dcno N aaoordance wRh all SAN JDAaTjCCUKTY nce Code;Slaldwds,STATE and <br /> FEDERAL caws. (4 <br /> APPUC#xT SIGNATURE: DATE: <br /> PROPEATY18USNES50wIER ❑ OPERATOR I MANAGER O OtWRAUWOmrEOAGENT ❑ <br /> pAmmw.isafft SumPANn.doeroreWpr:raeon b ripe IS necked Tiff@ <br /> AUTHORIZATION TO RILEASE INFORMATION:When appEcable,1,the owner or operator of the property boated at he abovo site address,hereby auelodre he release of <br /> any and al results,geotechnical data andfor environmentaf to a;sPssment klformat urr to Ole SAM JOA"CaAhY PIRRSC HEALTH SERVICES ENwtONaFMAL HE ETH DIAS CM As soon <br /> as O IS avaaabde and at he sumo Time N Is provided to me or nn represedalim <br /> TYPE Of SERVICE REQUESTED: �IT /7IL <br /> COMMENTS: �o V1 1 6 <br /> 2—/,5"0� J" ,>'nYA' tvsT� `a"nr1CJ7 � <br /> 7-kt Fysr,010-� <br /> '{' <br /> &,i� y Z a°bxI rn ar/c 3✓S 0 GG, �s�" ,f l,, QDr 6i f�T�/ <br /> SfCA <br /> c r.� . d2 7� 4� r. �il fz> fort dQ tvA � P1rfSA ax q•�� ' �/` <br /> INSPECTOR'S SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROvEDeY:)J EMPLOYEEtl: C'a(a C DATE: 7-6,5 <br /> a <br /> 4551GNED lU. I EMPLOYEE K: Uvwv� 4 ( DATE: <br /> Dale S!rvlYc Completed pit already Completed): �"/„ ' SERVKECOOE: cP I E:Lf 2-02 <br /> Fee Amount: Amount Paid (bar—� d Payment Date S' / <br /> Payment Type Invoice G, Check p S Received y: A <br /> S 66 ZS -Lr? <br />