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SERVICE REQUEST <br /> �.Type Business or Property FACILITY ID# SERVICE REQUEST A F-A 0000ald 6k00 3.:20 7,11 <br /> BILLING PARTY 13OWNER I OPERATOR C—A f <br /> FatILtTY NAME <br /> STYE ADIIRESS Jt� e I HAiC. i f��x 0 r <br /> Stmtnumb.. airxtian /�—T Soe.t Name T� suit�x <br /> Mailing Addres if Different from Site Addresses—7e?' <br /> CITY zip <br /> ZS L/2x <br /> PONE#1 --77 j� aT• APN# LAND USE APPtICATio" <br /> 8'7— <br /> PHONE#2 ar. BOS DISTRICT LocAmm CODE:. , <br /> CONTRACTOR f SERVICE REQUESTOR <br /> REOUESTOR <br /> BILLING P <br /> , <br /> / I <br /> 14 16 L y PH E# <br /> BUSINESS NAME <-- C -2 <br /> Fax# L <br /> MAIUHG Ss <br /> CrrY /� <br /> STATE zip ! � <br /> BILLING ACKNOWLEDGEMEtffN,the undersigned property or business owner,operator ar authorized agent of same,acknowledge that all site andfor project specific <br /> PUBLIC HEALTH SERVr-Es EwscN T HEALTH OVASION hourly charges associated with this project or activity will be billed to me or my business as Identified on this form. <br /> 4 I also certify that I have pmpa this all cation and at o e p rmed will be done in aeon cc will►all SAN JOAGUZCWM Ordingace LSjdanals. TATEand <br /> FEDERAL laws. <br /> i APPIXANT S[GHATURE: DATE <br /> PROPERTY 1BUSINESS OWNER ❑ _EMTORI OTHFltAusHOmAGENT flue <br /> frAcruGwriStZ89JKFurryprocfofnyXVJayonroalQnlsregvind <br /> AUTHORIZATION TO RELEASE 1NFgRMATI9N:When applicable,I,the owner or operator of the property located at the above she address,hereby authariza the release of <br /> any and al results deatei hnimi data andlor environmentallsite assessment Information to the Sue JOAMM COUNTY Pusuc HEALTH SERVICES&mRoNMENTAL HEALTH GMSION as soon <br /> as it is available and at the same time itis provided to me or my representative. <br /> TYPE OF SERVICE REOUESTED: <br /> l COMMENTS: f Y� <br /> ti�vl4iUN�1EN� <br /> INSPECTORS SIG E: CorcrORr SIGHATURE: <br /> APPROVED BY: DATA 02— <br /> ASSIGNEDTO: � A� f3'G! EmpLOYEE#: 3 `� HATE rs+� p 2- <br /> Date <br /> Date Service Completed ('rf alre dy completed}: SE CODE: . f. 'P f F� d(a" <br /> Fee Amount (� Oct Amount Paid a,(�'1 Payment Gate I LF(a Z i <br /> Payment Type ✓ Invoice# Check# rp 3 Received By: ��� <br />