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QX <br /> e <br /> —_— 07/24/2002 16: 31_ 20g4683433 <br /> FIFTH FLOOR <br /> F <br /> of Business or Property FACU.JIY IDA SERVICE REQUEST x <br /> 5 00%3c�lv J <br /> R/OPER(AATTOR �{-r <br /> I • w`'"J 1 L�CJ� BILUNG PARTY O <br /> LFACY NAME A�� <br /> DRESS 3 Z5 <br /> Address (IfDifferent from Site Addrtsat pLLQ PQt Q BTATE Z.P l m, APN tt20� l4-$ t�urD USE AvPtJGTpN tJHONE tl2 'T <br /> l O - p p 90s DNs�xtcr tDcrcnoN CooE <br /> CONTRACTOR/SERVICE REQUESTOR <br /> ReoUESTOR <br /> Btt.LJaG PARTY 0 <br /> BUSINESS Nme <br /> M utlNo ADDREs9 <br /> o z a.3 FAx CITY �Z� 1 o <br /> TE ZIP <br /> BILLING ACKt�JVfJVVLEDGEMcNT:Lthe urgersgned property or buaineas owner,a <br /> PVBIK HEALTH SEdvtcEs Ewv+tDN,extAl F/FXTN tlntSrDr+ Parua w audtorlaed agent 01 tome,adutiOwledge GqA ell site and/or Project nock <br /> noucty��� Dmje�a aDpvltyy+NV De DiUeC W me or my ewiness as Identified on tilt forth. <br /> I alto oartlfy Utal I nave Prepared tha e9p6mpon and that the WOAc tp be Perfomud wU bs stone inscAuaance with tW SAM JQAOUW CouwTv OAlinanoe CodSUWdrats.STATE and <br /> FEDERAL laws. �p <br /> APmx-uy SICNAruaE: 1 A E-ir <br /> DATE: 7-2 S d 2 <br /> paoPcary/BuswESSOWdER Q OP6UMRI O A DAC4KT 0-Y&M "nLTU tON TO RELEASE r,Wor&rM,GnmNi; o�yGP*cswrolthe Pf*PeM��Xlw above c"lddress,hereby aUMO a the mleaae of <br /> anyandaUresultsgeolaflmaldaoandltuanvimnmVsoe nforma>fon OMs <br /> b Ina SAN Jauouw Cowrry pslvuG HEALTH SF3rnCFs fxVruorwENtAt HGL71r a+ <br /> as A Is a WbM and at Ine sacro&rnt A'a:pmuded m ma or my rcpr=cjMVv* <br /> TYPE OF S[RvwE REp{rt±y-n D: - <br /> COt+r+t�rT�: <br /> PAYMEN l" <br /> RECEI�IE� <br /> no 0200 <br /> SAN PU8LIC0AQUIN HEENJH S Ol1NT+ <br /> INaPfGTOR'SSIGNATURE: ;:NVIRCNMEN�AL He AI <br /> APPROVED eY: _ CDHTRACfDR'S SNDNAIVRE <br /> ASSIG>, L 7 X30 -oL <br /> EYPLDYL 0- `?�. iQ OATTr; <br /> Date rvlae GomPJofod ('rf already eompteeW). 07-3 r7—0Z <br /> Fee Amoune �/ ,"7 eo Amount Paid sarom CODE I I -P I E. 23C) <br /> �- <br /> /, <br /> Payment Type Oa Invoice Payment Date 7 s, (o 2 <br /> tt .. <br /> Check II <br /> 5-17-3 Received By- .�- <br />