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�Lri',ECMVEU. <br />. - ,, onnl ccmMF RcniiFST is <br />Type of J AIN rp <br />FACILITY to 9 <br />cFRVICE REQUEST # <br />,'TH. <br />6ao30 <br />ass 5 7 <br />3ECEO VED <br />au.r+o PAM a <br />pvrr+at f pPF3ZAroR <br />UI.SPEcmR'S SIGNATURE <br />CONTRACTOR'S SIGNATURE <br />Facxtm NAME <br />Exp fi Cl <br />H <br />ASSIGNMTO: J9. <br />ElrPtrnrEEi` �to�rE /_ �_ -3 <br />S>rEADOREs�," <br />0CYJL' >7�/!-v� c� 0 -Cl.. <br />snexa . <br />Fee Amount �G 7 oa <br />IdaDing Address (if Diffe erd from SAe Address) <br />Paym ent Date i.. <br />Payment Type ✓ <br />CHY <br />STS q <br />PHONE it1 oa <br />APNX <br />LABOUSEAPPUCm =9 <br />o� <br />PIIONE#2 <br />BOS D>s'n= <br />_ = <br />L.0Cm=.t . ' <br />C0KTRACTOR I SERVICE RFQUESTOR <br />REQUMM�C �--- �'-� I1 ���905- BUM PAttttt <br />EKL <br />BusarEss NAIrE 79;e <br />ArxxsEss^6 _� <br />CITY Sume,4 zP �JC� <br />BILLING AC9NOWLEDGEbiENT: f, C» uudersWoed pmpeq or as busbawaer, opwtor or mAbadlted agent of same. ackMOIAedP I of she anNor projed tic <br />PVGX HE&T + Ss?vKa ENVEtCH MAL r arty sssodded wlb tisprged oradWlj wi be biled b me or mr busman as Ider0jed on M form. <br />1 aho oertHy fiat I taus prepared >tis ti per bmed wi be done in a000rdmm vft a1 SM JOAO of Cwm OrrGaeoce Codes. StaadarrlL SME and <br />PsaoPscrrlE3rIS+IESSOwst [J OPOWORIuWAM o OnCRAIrtNOIaMAGBR �/ _lam •, <br />r�{rrrti�iraKaffInSmEmpide. koTill. <br />ALrPIORIZATION TO R0.FJISE 44F Q[ When located attw above t b address. hereby agui:e <br />&,y "al mft 9*Aodx&ddata andbtHortaaton b tis SIw.lo�olur Caurnr Pue(oc r1Pxn+ SEKv>c>s +altAr FIEaLrl+ "as so�rr' <br />enrYonma>ratlshe . <br />TYPE OF SERVICE Rb UMM: VS % <br />COAUW-M: <br />-'AYIVJENi <br />3ECEO VED <br />JAN 2 1 20Q3 <br />S,4P4 JUA(IUIN COUNTY <br />r PUBLIC HEALTH SERVICES <br />`hVIRONNIENTAi HEALTHDIVISION <br />UI.SPEcmR'S SIGNATURE <br />CONTRACTOR'S SIGNATURE <br />APPROVED BY: O <br />Exp fi Cl <br />ATE I 0 <br />ASSIGNMTO: J9. <br />ElrPtrnrEEi` �to�rE /_ �_ -3 <br />. <br />Date Service Completed (d already completed): <br />SEl "m Cone:. <br />Fee Amount �G 7 oa <br />Amount Paid r <br />Paym ent Date i.. <br />Payment Type ✓ <br />Invoice # <br />Chea 8, <br />Received By. <br />