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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID Ir SERVICE REQUEST a <br /> — 0" <br /> OWNE IOPERATOR <br /> etuLIrrG PARTY d <br /> FACICY NAtt <br /> SITE ADORESS <br /> sv.t nvne.r or 1 Vk, <br /> Mailing Address (if Oifferent from Site Address) / G � C <br /> 4-7 'r ver~ <br /> crrr <br /> —464h4— , n 9 > 7- <br /> PHONE Al <br /> PHONE#1 E'^ APN 9 <br /> a3- Io0 - LAND USEAPPucAmN9 <br /> 2� <br /> PHONE It2 BOS fh5� LOCATION COOE- <br /> CONTRACTORI SERVICE REQUESTOR <br /> RLqu�ToR BILLM PARTY LI <br /> BUSINESS NAM P NE# W. <br /> L j <br /> 1 — <br /> MAiLJNG ADaR>ss 1 7 1 ' IC C)� 143 FCd (92 d" <br /> C)TY STATE LP {,— 1 r �D <br /> tcw �. T I+ <br /> BILLING ACKNOWLEDGEMENT: 1, the under-tried property er business awmar,opentor or authaTired agent of same, admawledge Urat aB srrle andlor projoct speaticr <br /> Puauc HEALTm SERvr-Es EwaRc.%T.rENTAL HELLTH Otv +hourly doiges ass up d wittT mLs project or ac:h*w0 W baled m ma army business as idenffx!d on ttr,-tar m <br /> I also car*mat I have prepared Ihcs appkzbon and=me work m be pertarnied wit be dam in aceardanca with ab Sue JOAWrI CCVrTY O+dinanCO Codas,Standards.STATE and <br /> FEDERAL law.. <br /> AppucAmT& uTURE: DAs' <br /> PROPERTYI BUSWi SS OWNER 0 OPERATOR 1MVLA.GER ❑ OTHER AUTHOP.LEDAGENT //8--' <br /> 9Aq�w7is not Cr U t� EdaZr:goof ad"I"t srbn tv zW b MI-W Ti ite <br /> UT-H0R gLTON TO R EASE INF0RMATI 0 N:Y1 xm appicabia.L the wffwor aperidor of the property located at C*above site addmss.hextby aubxtse aw release of <br /> any and au results,geotechnical data an!or arrvirrxuTmntalfsita as a=nent;mf,xmawn m tho SAN JOAaM G01M PUAY_HEALTH SERYKES ENV RO QA3rT&HEALTH DmsTon as soon <br /> as it is available and at the Same time A is provided to me or my represerrtattive.. <br /> TYPE of SERvnE REQUESTED: <br /> CoSilltENTS: ! 1,,,J V <br /> .-')AYMEf T <br /> INSPECTOR'S SiGNATU RE: CONTRACTOWS S rGRATUR E: <br /> APPROVED ter: (( �{ I EsiP L3T-- . Z z ' �, DATE: <br /> ASSIGNETo: rr�� .f EYYLOYEE#. DATE: �� � ��- � L <br /> Date Service Completed (Tf airudy completed): SERYICECCOE: d -P I E` <br /> Fee Amount: �" Amount Paid Payment Date <br /> �J I <br /> Payment Type invoice 4 Check S �Q-7 U 1 4 395-19 Recti,ed By: <br />