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y . <br /> SEkVICE fikQUEST <br /> (SERVREQ) Revised S113i4# rs � <br /> Fi1ClL#TY lb <br /> tD � B1Li,ING 1�1IRTY � C <br /> Wme 060 r_5 1-76— <br /> Y <br /> , <br /> tlt r . : ita 1-5?-f rb x <br /> i <br /> ' t .. .. <br /> • <br /> x�Mt#/bPERAtOR <br /> s <br /> r Y. <br /> tr <br /> NG RTYY ! N <br /> P10NE ii i y <br /> "d <br /> ' ! E 1} ; , /Wt1 lEi►`S .t ORONE #2 <br /> v V <br /> ° City 9TATE fiP <br /> f � <br /> • <br /> BOS 66i "`1 Casation Code � •� City t'ode -. <br /> 4 <br /> 6 <br /> .•o• i;ONTRACtOR.and/Oi' 2 x;• - 'I ftq, <br /> f{ <br /> �EkV1:IE RRQIIESTONk ., I, �' '"'" i. ILLING OARTY A/ G PHONE #1 <br /> r a. <br /> L .., �. # r I • fes_— f��r <br /> . a ,,.�^� • . •C7f.f�f�''{.- ...7.. of <br /> 1tAILiNG At1DhE�$ -•�. � � IJ{X <br /> �* YTA E <br /> t <br /> •. a <br /> `''•WLURd ACKltoULEMAENTi 1j the tixlerOgned owner; operator or agent of isms, acknowledge that att 61te md/or project specific„ <br /> •Pgi/E HD hourly changes' asioc6led With thi$ favi[#ty or activity it#tt be bitted to the party tdentlfied es the BILLING FART`f on <br /> ; <br /> dips r A. <br /> gage i o f th i s farm. J JAv. <br /> 1 also cprtl#y that I hare prepared this appt#cation 8rd the the trork to be pei'tornied snit"1 be done in ecaordence irtth alt S_AN <br /> *p , a'OUlk COWTY Ord#nence Codes and Standards = ' <br /> x: <br /> ars' APOWANOS 52GOTU4 i <br /> i <br /> �� "`1ALiTNORfZATt{Tii t0 JjLkAij tROORMATi011 Iii edditioit to the irbave; when epptid6li; tj this os+neer, operator or egent of same, of <br /> , } the �rope#ty tocatod at the above §ltb addriis hereby suthori a the release'of any att hesdUs, ilaatechhtcet hate andloc �< <br /> i <br /> env#rana►ent>stlslta assessment ihiorinatNx to W JOAOUiN COUNTY OUBLIC HEALTH SERVICE& EiiVXitt11#iENflkt NEitLiN blSti§iUt1 as soon es , <br /> It lsavaitabla and <br /> At the" anme time it t§ pFauded to ane be n`y reprtsentattve. <br /> RM s 1.i service Code Q tr <br /> 1:'• Nature of tei-,AkkialeA:t; <br /> f'` lis <br /> Ahi 104 tf.to <br /> R t6Ye tG7 Date <br /> i ete sei�vic� oiripieted kA464h Attioh kegdleed• k 11 It PRc1GRAl� ELiltrot2�Q0 <br /> ♦ <br /> fel.'..: {. . ... .....,.f .ava.. •i '1 <br /> , <br /> w <br /> x i <br /> y ?„ dee AmatmE AMDmi t {r610 bate of Payh*ni Peyment Type Receipt #- check #.: Rtcvd <br /> ,r .J <br /> e' <br /> RENS l�ZI 1 I SUFV / /. . Abolt to <br /> i I <br /> l <br />