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SERVICE REQUEST <br /> Type of Business or Property FACILITY 10 rr SERVICE REQUEST S <br /> 12 A_7 LZ-12s- <br /> OWNER/OPERATOR /1 BUJHG PARTY❑ <br /> FAcwN NAME <br /> SREAODRESS <br /> �Zog ailingAddress <br /> a Sb•.rN.ro. « E . Sit el 12�(If Different from Site Addressl <br /> CITY STATE /} yl ZIP <br /> PHONE#1 APN X LAND UsEAPPucAmN 9 <br /> HONE fI2 Ecr. - BOS Otnwcr LOOATIONCODE- <br /> .a-. CONTRACTOR/SERVICE REQUESTOR <br /> REQUtssTOR Btumc PALM❑ <br /> BuslNEss NAm� 1-2d <br /> G/ !� / r. P�'F <br /> �'MALLwc AntxtEss4 / L�� L,�� � � . FAz1F /� / / <br /> Lym A,C ^Nf STATE Z8 `752- tel >-r fT <br /> BILLING ACKNOWLEDGEMENT., L the undersigned property or businass owner,operator or authoraed agent of same,admow"a Owl all ode and/or project specific <br /> Pu¢uc HeuTH SERvICEs ENvac"horrALHEAUH ONr"hourly dtarges associated with era pmjedor acMity will be tolled b me or my business as identified on dib form <br /> .'also congy Ihat I have pm application Me b be pedomwd will be done in acmna daWM as TY Ord SAN Jo wN Cmwencs Codes.SfarMeNs,STATE and 1•- <br /> —FEDERAL IoM.KA1r <br /> /G U <br /> APPlT SIGwNRE: � QAIE: ~ / <br /> r PROPEATYIBUSWESS ❑ OPERATOR/MANAGER ❑ OTHERAUTN%ItEDAGENT ❑ <br /> YAPEU�Tsrs :AQLLCPum.poddwdwtratlon NailW hnvu:ed TNIo <br /> AUTHORIZATION TO RELEASE INFORMATION:when appkablo•L me ownaror operatorof dw property bated atfw above site address.hereby auCrWze the mism of (� <br /> any and al results,geotecimi al data and/or w4crunenbWsim aaexunent inbntwJan b Op SAN Jw m CGINTTY Puuuc HEALTH SERvKzs ExvRorwErru HEALTH ONL=as soon I <br /> ...as 4 a available and at Ore same time it is provided b ma or my rapresmfative. <br /> TYPE OF SERvicE REQUESTED: <br /> OMMENTS: PLrd <br /> /y,,�3 •b 'e / JV y 2 r �f terP2111I <br /> r YJ1021.Q 5 f2�L'� tel Lr 7`/,e vwv>t� r ple�n s Tv bu< ,� �� <br /> /ten v,, T� s,y ,, -74a <br /> ry r�� <br /> I z �1-l)R✓edr 077 2 <br /> (� o / ti l✓�w�S oZ _ <br /> 5; '��ly� l oZ LAB Pf�� C4 �r N��1J N ` NT <br /> f. � n 1�•e��i / "`'.�"./- lam i/ 7S SrNv �GFNT�+IHc I N_Ir;r. <br /> INS00, <br /> PEL"fORS NATO COMmAcmiesSIGNATURE: / / <br /> APPROVED Sr. n P Ems;L: T0.5 DATE —/t/ <br /> ASSIGlrm TO: -��_/ ` v �- ver EuPLOYEEtt: DATE:: <br /> .Date Service Completed-Cif already ccmple EI ICECOt -PIE <br /> Fee Amount Amount Paid O Payment pate <br /> Payment Type invoice tf Check C S3 Received By: <br /> bw <br />