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i <br /> f <br /> 0 <br /> SERVICt:REQUEST <br /> Type of Business or Property FACILITY 10 SERVICE REQUEST# <br /> 29 2 7� <br /> I �WMFRI OPERATOR BILLING PARTY 0 <br /> 5'x13 N <br /> FAGiLTTY NAM)" <br /> SITE AwRess /wV� <br /> i 1 Q SastN.++Dr �'` ' Q� St wname Typ. Suit! <br /> Mail' Address If Different flom Site Address) <br /> o 6 a F. oLQG <br /> CITY ZIP <br /> � -5- 60/ <br /> PHONE#1 EXT. APN 9 LAND USEAPPl.cArooti 9 <br /> ( ) s _ S �' 2 - 0 3 0 -�01 <br /> PHONE tf2 BOS DtSTRrt:r LOCATION CODE- <br /> CONTRACTOR <br /> ODECONTRACTOR I SERVICE REOUESTOR <br /> REQUESTOR BUJNG PARTY�,t <br /> I d <br /> BUSINESS E PHGNE# [v <br /> G010,20- 6 <br /> IllAst.rHG d O D FAx 9 <br /> CRY / STATE ZIP <br /> BILLING ACKNOWLEDGEMENT:I,4w undersigned property or business owner,operator or authorized agent of same, adaiawlodgo that all sde ardor pwod apedfic <br /> PUBLIC HEALTH SEMACES&1MQ14IEWAL HEALTH DMSM hourly dwgcs associated wiM aria projector aWdy wits be b9led b me or my business as identified on to tbnn <br /> I also cerW that i have pre this application and Nat the wont 6o be performed wd be done in ao4vrU=with 4 SArr JOA(aM COUNTY Ord a&=Codes,Sfandards.STATE and <br /> FEDERAL taws. Jif <br /> APPLr-W SIGNATURE: I I DAM <br /> PROPERTY I BUSVWSS OWNER ❑ OPEI:ATOR I MANAGER ❑ OTH;MAunroF=AGENT <br /> rAPr XAWiS not 1*VLU"iproof a(Moortratloe to ai r S nQuiid-Ir TWO <br /> RUfHORQAT),ON TO RELEASE INFORPr gM When appkable,Lim ownworopwd"of the prop"betted at the above site addimss,hereby authorize the release of <br /> any and al results,9eatechniml data arWor a Ar onme►talfsite awam meat infomTatbn Noon SAH JQwuw Cojm PuMx HEALTH SERYEES Ew RorwaffA.HE&-.m ONWMH as soon <br /> as d 4 avaMbie and at the same time it is provided to me of my representatm <br /> TYPE OF SFmICE REouesrED: c a I <br /> a CO3riLE7TT5: � /"'"y Z <br /> r- uPAYMU,' f �a <br /> RECCI V E+-fMAR 2 721102 <br /> 1 v <br /> b <br /> saiv IC AQUINHIPITH c PIN J r . <br /> PU$LIC Flf.A.t,l'!�crF}+fi;t <br /> L7JVIROIJr,�ENfAI �ilR+.TriLpV. <br /> INSPECroWs SrGmATuw CONTRACTOWS SIGRATURE-. r ` <br /> J APPROYED BY: J I S / BATF~ <br /> Assram To: F oYEE#: DATE: <br /> e <br /> Data Service Completed (rf already completed): S CoOE: <br /> Fee Amount �= Amount Paid ,� g _ payment Date 3/2-7 OL <br /> payment Type ,/ Invoice 4 Check 0 � O0 r, Received By: � ,,/ <br />