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V <br /> SERVICE REQUEST <br /> ! 'ype of Bisiriess or Property FACILM ID# SERVICE REQUEST# <br /> Cw4c° CPQ°A70R ` SLUNG PARTY � <br /> rn.-L'TY NAME <br /> SUE ADCR-;:5S- i= -=1� <br /> 7ypi, 1 <br /> Marling Adoress (If Different from Site Address) y 1 r - <br /> 3 1 t 1 Z A4JI�- <br /> I' <br /> - SPATE �, ZIP <br /> Pf,Cn. 1 Err APN# La}+DUSEAPPLr-Awx# <br /> PnChE w2 Q �r] T --=$d•�� A1CCr=�1�- ~�N==LocATION Cooe- <br /> CONTRACTOR/SERVICE REQUESTOR S y <br /> i BIU.ING PARTY <br /> r <br /> BLSiF,e55 NA}+E }"•� K Y', r' PONE"" � a MT � <br /> M,,LwG AaCRESS FAX j <br /> r•� �-� STATE �I Zip <br /> , <br /> FILLING ACKNOWLEDGFMENT I the urrd"rwq d property or busineu oveier,operator or authorttad agent of same,advivoiedge that al sde andfor prolett sC <br /> -_=-C-E N mu SeR'llas EwaoTAL KEALTH Orvtsroet hOurtl duu3es a%wwted wdri Mpmpdor acdyq wil be bled to me or my business as►denffied on taus form <br /> 1 asc te^-j a,1:ave preMred this appi�awn and trial the iwric to be performed tint be done In aassrdance with d SM JGkmm COUNTY Ordinance Codes Sfandardx <br /> ,r MP <br /> =tti ax5 i <br /> cI 'r GATE /? 1 <br /> ,c. OPSWOR f Mrs OZ R C7 Ormim Aurru ZM AGENT ❑ <br /> tl Avrt cwT a rrt�e BLJtC P u+rY pin, of wthor>xxtlon e7 JUg11�+r+41+F� <br /> Tilts <br /> 'UT�ORrZATION TO RELEASE INFORMAT19 When appfimbla L the or+ner or opendor of the property bcated at the above slte address hereby authortxe the <br /> -y arc zJ^tst ;cote Rlcai Data arx5lor ermronmeauaVsrts assessment n(armallort the S+W JQAOUw COUNTY RAUC HEALTH SEWMS Er ADi'ul9rfA4 HEx;�r OMS /as <br /> as•s a.zvzo+e anc at She same we rt is pronded to me or my representa0ve. <br /> TrPEoFSuvvicEREQUESTEo <br /> C:rldtiE}+T$ •<` f,„s :iS}! %^� r a�a-S t` ,, r t:.J „ <br /> n <br /> I MpEr:;Ws SIGRATURP. CaNniACtoa's SIGRATUFM <br /> I .•?P4Ctiu=� <br /> AS.SrGhE2TO 'DATE <br /> i Date Service Completed (d already completed) ', ,. ��r. SE C,=000E .r',�>;,t s;�` :, <br /> •" `� r i Lfx"• �• �;- <br /> P f E- <br /> =ee rmcunc Payment Data ' <br /> � ,rte . <br /> 3 , P3)rMer't T vpe If1Y0tGa# �'t+t= check rz�� .�§•,�'-'Z- ^r+-r�^�•r,,:._ Rwelved ST i <br /> i r.L� _�+,C�+k{�s1Y`'1r7riS:t�A.S;i•{�:�c''>'�l'�,f.r�v�1''hv`����', Kn r' s'� .., I <br /> � _ t ` � � •..� . i.i? .f`T�h{.►!re r��,^ `r,�'S1 �..-4 °t`.�-�'J ...rF.r ',.w',� 4 `� <br /> - - - _ - - _ = i � ' •<*3' Iw��},y�tj„��3.t�Y G `'�'11���7� •i�����1,��,"r..r� � -j _ <br /> r.�•, ...:.` w'r(•Sda+'w4b> j,1 r�Ci.,.4C <�?�{$Ik1 trued'''{s�'Yv`4\> <br />