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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID 9 SERVICE REQUEST:: <br /> Ow RI OPERATOR G`-`"� BILLwcPARTY <br /> FACILaY NAME 6 <br /> cj'av O Q t F1 S=ice ISIc:_L--4-x- i.6 F 2Lc <br /> STTEADDRESS '� �� AL <br /> Mailing Address (If Different from Site Address) <br /> Cr STATE ZIP <br /> (f—A tai <br /> PHONE 91 EXT. APN p LAND USEAPPUCAT)ON rY <br /> ( <br /> PHONE 92 UT. BOS Du tRi 7 LOCATION CODE <br /> CONTRACTOR!SERMF REQUESTOR <br /> REQuESTOR/! BU-24G PARTY❑ <br /> Busmrss NAraE PHONE 9 [zr. <br /> MAtIyADDRESS FAX S <br /> O. <br /> CnYyo Tt*i STATE��% e 2© " <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned prop"or business owner,operator or author¢sd agent of same, admawtcdgo that alt sale waor pmjoct specific <br /> Puouc HEALTH ScmcEs FIMRGNm rjfrA1.HEALTH Orvcwm hourly dtarges as,ociated with trio project or aCMity will be bdIcd to me or my business as identified on tlmG Corm <br /> I also cortify that I have prepared this apprxation and that the work to be performed wd be done in ao=danca with aA Sur JOAQtm COUNTY OiVinanoo Codos.Standards,STATE and <br /> FEDERAL laws. <br /> —Zf Z <br /> ArrucAKr SrGtaTURE %G�: ,tel� -� e—LSi.+ 8 <br /> DATE: 'd. <br /> PROPERTY IBtuurESSOWNER 0OPESrATOR/ 0 O7HMAUTHOFIMDAuja O <br /> AapurwramtDm,@/,(.M poordwciartuOwto4Wbr"A"d T!U♦ <br /> AUTH0RIZATIQN TO RELEASE INFORMATION:When appkable,L the owner or oporatot of trio property located at the above sits addms.hereby audxxin the rebase of <br /> any and all results,geotechnical data ar0or emAronmentaYsite assessment infortnatlon to Che Sur JOAanr COUNTY PUBLJC HEALTH SERvhCES Ewco"AaENTAL HEALTH t msx)N as soon <br /> as d is available and at the same time R is provided b)me or my mpresentativo. <br /> TYPE OF SERYICE REQUESTED: /S • I <br /> COM1dflfrS: / T` <br /> PAYMENT <br /> RECEIVED <br /> stily JOAUU N GGUt"? <br /> nt!6i_IG HEALTH SERVI, <br /> INSPECTOR'S SIGNATURE: COKTRAcToWs S7n,NATURE: <br /> APPROYED BY, \ EYf'LOY`-t-¢, +DATE: Z O L <br /> ASSIGNED TO: ELPLOYEEt. fr+� DATE: 3 -U2 <br /> Date Service Completed (f already completed): i� SOME.CODE: (Q g` P/E.- -2-30P <br /> Fee Amount: �I Amount Paid Payment Date <br /> Payment Type �o Invoice 4 Check 9 Received 8y:-�i j�, 4 <br /> • h <br /> . �t <br />