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10/21_/2002 09:24 2094683433 FIFTH FLOOR <br />SERVICE REQUEST <br />'' FACiLiT'! ID # 5E'tc VICE E�flUEST � <br />Type of Business or Property ©���� S (�— �� <br />pvvNER I OPERATOR `I All \ i ry U C 11 1! M <br />FAC ff NAME �— n ►� <br />s <br />S <br />svw.r .r oma= <br />Mailing :ass (if Diflerent hom Site Address,% <br />PAGE 02 <br />BILUNG PARTY vr <br />STATE . I P <br />AP N # LAND USE AJ�Pt,rCATM # <br />St3S DISTRICT LocATM COOS <br />CONTRACTORI SERVICE R£WEST Ba11NG PAArr <br />Exr. <br />BUSXM WXE 11 <br />STATE ZIP <br />ed to ar business ovmer, apentor or authorised agent of same. sckn d98 Crat al sft andior project sPedk <br />t3tLUNG AC}(NOtlVLEDGEM'cNf: tithe Ipldersign P FAY vrsbl project 0,actt,* rW be bMed to me Or MY <br />busirteas as dented °" this ' <br />Pt retx.I• STH SERVICES EyYtF alwiTAL HEALTH DMsraa hounY r9 COUNTY Ord�rarrce Codes. StaMUIP . STA -1 and <br />red itra app ->m^ and that the wWk to be pertrr be daft in acccrdar>ce with as SAr+JOAOuut <br />a also �'Y sat 1 have preps £ ` / _ q` O 2 <br />FEDOM lays DAT <br />TLgs: <br />papLrr„rT sIONA. p� ' D <br />OPERATOR I MANAGER 0 to s4" is � rI rr. <br />PRCPERrr I M NESS 0M R YAppLcj rrardrberr.,.rP authorize the release of <br />-90 <br />1NF R ioca�d at the above site addeess, bere6Y <br />the SAN <br />A TH H TO R N: when ap;Aable. L to ° PUeL)C HEtiTH SERv10ES EWROM,,-KTAL HEATH Otv>• " as soon <br />hfbmad- <br />any and a9 lists. geotechnrr�l dam w4v -Arc menlaVs to assessrnern <br />as a b evadable and at the same dMe d is provided to me or my rEP <br />TYPE Of SERV CE RFaMTEX ' \ <br />����E\7 <br />_0 , <br />�\N <br />� �— aN \0 QPLZNEP H��\3\ON <br />CONrRA=fes saoTUR£: Z <br />banCMFeS SrNATURF:e. �ti tc M c td !)AV --'d <br />APPROVED lir E —O Z-- <br />DATE: <br />ErPLaYEE#: 'j S 1 g <br />ASSIa+ M To: pwmcoot✓ 19 P l E:. 23 <br />Data service completed (1f°D°'a�' Payment Date l l I �{ ) "� <br />Z --) Amount Paid tj�a (off <br />Fez Amount: <br />payment Type Invoice <br />NOV 13 2002 <br />ENVIRONMENT HEALTH <br />PERMIT/SERVICES <br />