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I i —JW— 14J1-0'� 10 - ``JAM F KUm P. 3 <br />SERYICE MUM <br />Type of 3u2iness or Propeftf FAC -11 -MY it) SERVICE REtxUEST R <br />RIO B1tLINC PARre ! <br />QAC) , AME ,,,,� �l'�\`► \�T �'y 'e <br />Srrl ADDRESS <br />6blatNumw n 9uw \°+J' type } 5mtti <br />Maii4ng Address (if Different from Site address) <br />zip <br />1 T• APN it ! Lmo Ustd AppucAuuN 0 - <br />f 125 j <br />PROW 12 W SOS CUT OCT LOCATVJN Goa$ <br />COWPAC70R I SERVICE REOUESTOR <br />BILLING ACKNOWLEDGEMENTt, the undemkji+ed property or business owner, oovator w authaf&ad agent of same, amnowledge hat all site and/or project spoeic <br />PVGLIC HEALTH Swous EwmwEmTALHEAL114 DNSVN hourly Ones asSaGaW wA this project or activity will be billed to me or my busineu as idenUt;ed on th s form. <br />i also c rdt that 1 have prepared appkatlon and Mat the wont i0 be m -formed w3! be done to accordance wM al Sm JQAouw Counrs�r Ordinance Cedes. StendardS, STATE aad <br />Pi_RRI. taws. <br />. pKjc tvr SrcmATua6: DAM <br />P�PEYTY! BUSR�SS OWNER CPERATOR ! . CrAA AurmoPrM AG&r'r <br />�` .xe�rr5rrrsFrrB praoPoP ro.:/ga+�rvv 7irre <br />AUTHORi2AYlQN Ig RELEASE INFORh ATIQN: When a owner or operatrrr ct a>e property Stec at hs above site address. hereby aurhorizt Gze s lerse of <br />arty .and ail! tF3 uft. geolodr * data arWor anviranmerwaUsite 2s3essment infomraWn to tre So JOAwim Cajmrf PUBLIC tis TH SERvms EwRoNMENTAL HF.ALT-o OrIrsioN as soon <br />as R is available and at Sts sorra brit® It is provided to rn or rrry rspressrtatfve. <br />TYPE OF SERVICE REQUESUM N, <br />Nk4hr,.., . <br />APPROVED SY: ��CAe <br />EMPLOYEE # tO� (DATE: <br />AaSN3HED TO: EMPLOYEE 9: DATE: <br />i <br />Date Service Completed ilf already completed)- Si�+rKs CCt)E: �( � i PIE <br />Fail Amount- �' Amount Paid , 00 � Pagmert Dale 1) /19% 1 g i <br />Payment Type �� Invoice # 1check # f Received 3y: <br />I - i <br />