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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID K SERVICE REQUEST <br /> OWNER I OPERATOR BW—NG PARTY❑ <br /> M K . <br /> FACILM NAME <br /> S SoR FYI U <br /> SrTEADORESS <br /> 09A W <br /> �' 1. sm.�a.rer prawn CJIr' - mvn.m. sw., <br /> Mailing Address (If Different from Site Address) <br /> CITY STATE IP <br /> OD1 <br /> PHONE91 CAT. APN# LANOUSEAPPucAmN,Y <br /> (Z64) 334 - 6523 <br /> PHONE#2 ExT. BOS OLSTwcT LOCAPON CODE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> REQUESTOR Btl w PARTY <br /> MOR-Ty TCSc <br /> BU /NESS NAYE PHONE# ear <br /> �Ic- Z 3 34- (�5z 3 <br /> MAwNG AooREss FAX It <br /> Z 1 W Zos 334-2611 /, <br /> CRY STATE CA . zip ,,46 <br /> BILLING ACKNOWLEDGEMENT: I, Ne undersgned property w business owner,opmtor w authariTad agent of soma acfaloale67o Nat all sde and/or pmpd speafic <br /> PUBLIC HEALTH SERMES ENVWCKiv-HfAL HEALTH ONr"hoWy drargc5 aswoand wdh Na pmfed or a=ygy wO he baed N me or my business as identified on this torn <br /> I aao wrtily that I have prepared Na appti abon and dut Ne work b be performed wR be done a=xdarwx with all SM JOAolm CwNrY ONinerra Codes.Standards,STATE and <br /> FEDERAL laws. <br /> APPUCANr SI TURE:, CATE, <br /> PROPERTY/BUSINESS OWNER ❑ OPERATOR/hWUGLR Ll❑ OTHERAUTHcri1FDACENi ❑ <br /> IAFacw x$ (ar BatwGPA4n.Prodawewtatlar ro3'.6rqu.wr Till, <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,L the a or operatord Ne property braced at the above site address.hereby audnrtre To rebase N <br /> any and au resuR's,geetechi [data anJlw mvitonRterlmiY W asxilvrrnt infoml0tbn to M Sm Jotctm COUNTY Public HEALTH SERVICES ENvNONA CHTAL HEALTH ONeaom as Soon <br /> as it a availaWe and at Ne same tme 4 a,provided to me or my r(afacserltaWa <br /> TYPE OF SERvrcE REQUESTED: SUI ,Q(,c J(,ybS ur�pCE ( � -f-({ I,yl lf7p flan �, <br /> C wh e or <br /> COMMENTS: <br /> 9 3° awZ //1ceL �I�I PAYMENT <br /> i4c 3 S" ;s� RECEIVED <br /> APR 9 M2 <br /> INSPEUOR'S SrGRATURE: CONRGCm es SIGNATURE: <br /> APPROVED BY' E71PLOy`�II: ^tiJ — DATE: ,i. ..9_1 <br /> it <br /> AssrGHED To: EMPLOYEE#: ,j "� DATE <br /> Date Service Compfeted (rf already completed): SERVICECOOE: S C 3 I 'P I EE �� 3 <br /> Fee Amount `'� L Amount Paid 17 b -ttU Payment Date u D P, <br /> Payment Type Invoice# Check# geeelvedBy: <br />