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10/20/2000 11:35 209468343 FIFTH FLOOR PAGE 01 <br />SERVICE REQUEST <br />Type of Business or Property FACILTrY ID <br />SERVICE 1REQtJESi � <br />OWNER J OPERATOR <br />BILUNG PARTY C <br />FACIttTr NAaet: <br />Sim ADows <br />ea ar cam„ k <hi C ®r til 9,L V.b , <br />Steal Nam® <br />Mailing Address (it Different from Site Address' <br />CITY <br />STATE ZIP <br />PHONE #'I APN # i.AN4 USE APPUCATmm # <br />PHoNE#2 Exz 90S DMTR= ; LgCATK3EFC <br />oos- . <br />COffMCTQR J SERVICE FMOUESTOR <br />� REQUESTQR �PAJR"" <br />BUStNM NAM PHONEEsz <br />irlA,uNG AODRES$ FAX# <br />cirf 1� STATE Z1P <br />BILLING ACKN0WLEDG8MENT.- I, the undersigned property or businew Owner, operator or authort ad agent of same, admmvWge tot all sea and/or project specft <br />Pusuc HEALTH SERVICES E1w MONMENTAL HEALT14 OMSM hmmr charges aSSoaated with Thi . project ora&idy wil be blued to the or my business as idwi fied an this berm. <br />1al M* that 1 have preparddd yLthiisa� PPkA Cn &W that the w0ft to be perfaMled Wil be done in a=rdanee wilt ae SAN JCAMIIN COMM 01TMnw Cedes. Starzderds. STATE and <br />ItiPPt.IGAtrC StGNATrJRE: v ` 0J <br />®' Di6tE <br />Purr J BMMW C MER ❑ OPERATOR! KWAM Q Q1iiER AuTFraw2fip AG&Mt ❑ <br />YAPP.rwl'isra tarFAMY PVdofavftro=d=mSip Titro <br />AUTHORIZATION 7O RELEASE INFQR-MATION: When appficabte, I. die ownerar operator of the property located at the above site address, hereby authorim the release of <br />any and aff results. geatecnniml data and environmermyW am== infOrn dOO t0 the SAN JOA4uitr Cmmry Pueuc HEALTH SE €S FwRmAeffAL HEX -,A ®Iv mm as soon <br />as Ifs avabble aN at the sante &m itis provided to me ormy mpmellWm <br />Type OF SEWCE REQUESTED: <br />Cont�rrrs: <br />APPRomBY. <br />i Ptt:Y'�c `: <br />QATC <br />AsstcNmra: <br />EmpL®YEE#: <br />DATE <br />:Date Servide Cempieted {ifalaeady ea,mpletedj: <br />SatvlMCODM <br />Py E- <br />Fee Amount: <br />Amount Paid <br />Payment Date <br />Payment Type Invoice 9 <br />Chertc #Received <br />By. i <br />