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SERVICE REQUEST <br /> Type of Business or Property <br /> FACILITY IDR SERVICE REQUEST Z <br /> (-Pe 7-0 L aILUNG PkRTr�3 <br /> OWNER 1 OPERATOR <br /> e v( G(� f Alves <br /> �fl N N r <br /> T,ea ti1�/ <br /> SfTEADORESS S"dtHsm■/ tro■ I Suil■t <br /> (ZG1S� sten Humor 71r.eoon <br /> Mailing Address Different from Site Address) <br /> Sa , l� STATE Zip <br /> C17Y <br /> N LAND USE APPLICATION# <br /> PHONEAP <br /> 1 N 9 3 Z/p -/g NO 1-f.5 A r 7?-, ,'5 <br /> BOS DISTRICT LOCATION LODE <br /> PHONE K2 <br /> f 1 <br /> CONTRACTOR SERVICE REQUESTQR <br /> BILLING PARTY <br /> RE UFS7pR�D _ <br /> CPHONE I EXT' <br /> auslNEss N P Cj/di✓----- f2: ��7 /` �7 <br /> �L 9i�G - l <br /> (7 � 71p q <br /> � � <br /> MAILING ADDRESS zipSTAT <br /> � <br /> G <br /> 31LI ING ACKNOWLcDGEMENT: I, Tie undersigned property or business owner, operatorroaorraauthorized y Will e sled to me or my business as dentme that 39 ed on this formite and]Cr l�Ste` <br /> PuS.IC HELI i t SERVICES&,vIRONMENTAL HEALTH DMSION hoUny Cnargea a5SO=led With MIS Pml <br /> I also cerdy that I have prepared oPlicadon a 31 the`Nark to be performed wwl be done N a=banks h all Sur JaOuw COUNT r Drdrnance Codes. SlandarUs,STATE enc <br /> FEDERAL laws. S - 2-g <br /> DATE.• <br /> APPLICANT SIGNATURE: <br /> OPERATOR/ OTHER AUTHORIZED AGENT ;,+le <br /> ?ROPERTYIBUSINESS OWNFIZ Q risnotftdL w'P'Rn prooiai2udwa don tosJcnisnWnd <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable.I.ale own or operator of the property boated at Ne above site address,hereby authorize the release c <br /> any and all reswts,geotechnical data andlor envlronmentaUstte�r�ne�n�fo motion to die Sur JOAOUW COUNTY PueuG HEALTH ScrlvlGcS ENVIRONMENTAL HEALTH DNISiON as Boal <br /> as it is available and at the same time it is provloed to me or my P <br /> TYPE Of SERVICE REDUES7ED: —- — <br /> 01`fuI L T 72I <br /> I <br /> I <br /> COMMENTS: <br /> jAY28V <br /> I <br /> ka�.P �UnIJUI!4 JAi I'I <br /> WUOI:C HEALT{;:aEndICES <br /> iWIRCNIuFN ITAL NFALTH DIVISION <br /> CONTRACTOR'S SIGNATURE: <br /> � INSPcCTOR'S SIGNATURE: �"� I DATE: <br /> EWLOTEE+: <br /> -'?PROVED BY: <br /> EMPLOYEE+: I DATE: <br /> -155IGNEO 70: <br /> ?!E": <br /> SERIIC%ODE: <br /> ]ate Service Completed 'jf already comaieted): <br /> Amount?aid I Payment Date Klq q <br /> =�e amount: <br /> 1 I Checx: O Received dy: <br /> P-lyment Type invoice 3 <br />