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�-, <br /> SERVICE FMEST ---• <br /> Type of Business or Property FACILITY 10 9 SERVICE REOUES-L9— <br /> RC i AL i Sy ANT/R <br /> OWNER I OPERATOR BILLING PARTY❑ <br /> FACILITY NAME <br /> /✓f <br /> SITEAooREss ICASSON !LV <br /> Mailing Address (If Different¢om Site Address) <br /> CRY STATE ZIP <br /> PHONEIIt ER- APN t{ LNo USEAPPUCAMNU <br /> PRONE tl'L B05 DISTRICT LOCATION CODE <br /> CONTRACTOR SERVICE REOUESTOR <br /> REGUESTOR <br /> BUJJnc Putrill <br /> ob A/ L�N,cS N� <br /> BUSINESS NAME PHONE <br /> VHGLE / # - / Qr. <br /> Q <br /> MARLING ADORESS FAX G <br /> �•O . - � 7 c',68. �sy <br /> CITY 2 L Cc--e STATE A 3 / <br /> BILLING ACKNOWLEOGEMEflT: I, the undersigned property or business ovmar,opmtor or authorized agent of same, adow.iedge that as site andl0r propel 3pedfK <br /> PUBLIC HEALTH SERVICES ENVIRCNaEMAL HEALTH ONr"hQUdy dld19e5 associated With CM project a arSvi(y Will be Meed to me dr my business as idcnofied on this nnn <br /> 1 also mrdty that I have pmparcd Nis ap bon and that thOAfti to be PWOH11ed wd b0 done n 40=11w=with as SINN JOAarn COUNTY Grdwsma Codes.Standards,STATE arM <br /> FEDERAL taws. ,. n <br /> APPIJCANT SK.NATIIRE: DAM 6"Z-7 j0 <br /> PROPERTY I BuswESS OWNER O OPERATORIMANACER OMMAU17HORMAGENT H ' <br /> fAP{VV =X(CIIRLtrr:P.an Pqy GewmarCabw b ripe is-7,ar T7f/• <br /> AUTHORIZATION TO RELEASE INFORMATION:When appkab10,L Me ovAter or operatorOf the property IorahM at the above sits address.hereby avautze Me mieese of <br /> any and all results,geotedtnral dam arsllor emrtvrunentaysm assessment nfamaGon In the SAN JOAww COUNTY PwOC HEALTH Srlwx;E5 EnvutoraENTAL HFXTH OmWN as soon <br /> as it Ls available and at the same time R is provided In me or my mp mentaha <br /> TYPE OF SERVICE REOUESTEO: <br /> L /7 t TU D L -F VIEw <br /> COMMENTS: <br /> - �r✓,� �il/ftr�z ��� �� -rte ,�,►�,�t,�✓ <br /> INSPECTORS SIGNATURE: C CONTRACTOR'S SIGNATURE' <br /> APPROVED ar: A/ ELPLOY`-II: 4(S J DATE. <br /> ASSIGNED TO: S eU Li EMPLOTEEtt: -Z �/ DATE <br /> Date Service Completed (Tlaalready completed): V SERVKECOoe P I Z�Q <br /> Fee Amount I—7 Q u cl Amount Paid Payment Date <br /> Payment Type ! o Invoice k Check 9 Received By: <br />