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~ 06/27/2001 13:57 2094633 FIFTH FLOOR • PAGE 05 <br />P <br />SERVICE REQUEST <br />FACIUTY to � SERVICE REQUEST R <br />Type of business or propertyFv) <br />} <br />• 8iwxc Palm C <br />GWNERI OPERATOR ^ n �J <br />FACW Y NAME 0 U 1 e - S fi P H „K�� S / <br />SITE ORES / ^ S . OLIVE V rrc. sem: <br />C7 V srcee oma°^ <br />Mailing Address (If Different from SdeAddressi <br />STATE ZIP <br />CITY <br />Exz' APN# LPNOU"SEAPPLrAmON'ei <br />=CS <br />= Il gCS DLSIxICi LoCATsoH.CaaE . <br />CONTRACTORI SE WCE REQUESTOR <br />- 81wN(3 PARTY d <br />PHt]NE # <br />6UslNESS NAME "T21 A t.((�E Exr E74 V 11204 M ML)FAX <br />'70 Z D <br />?UuNGADDRESS Z5ZS#^! BU1ZBAi,1K• VLUD 91 a % <br />STATE ZIP <br />Crrr L3 LI IZ 8 A -hl V-014 <br />STATE <br />ent of same advtGxley4e trot atl sig anrtor p ojeG sperm <br />31LL1NG ACKNOWLEDGEMi NT: L Nte unders5rred Property or business owner Lor a will beabillEd to me or my business as idem an tahis :ant. <br />Pusuc HEALTH S�RviGES Exv�Af Nl�tiAt HEAL Tt t DNtssont hourry dim es assoc ztetd Wit' Standards 5r TE and <br />I atso certify that 1 have prep;, � this appfitatian and tlrat the work to be perronr d xd1 be done in aaudance with ail S j�; QwN Cour Ordinarr� Cedes <br />FeDEtuL fawn. <br />OATS <br />APPUCAXT SICRANRE: <br />p CPER1TQR1M-1gxGER 13 Oitaur R�ac rrr Y" rrcto <br />PPOP�TY 1 HUSi;!_SS +� If APvt.c; xl is rxw 8» � nc P.�. pocf of xi�arira�oe to sib it rcav� <br />&cable 1, the owner vt o perata r of the property 1oca�d ai the above s"Re address. hereby authorize the release of <br />AUTHORIZATION TO RELEASE INFORMATION: When app EwFzomu AL HEAL ra Orvrsta+ as soon <br />any and all results, geotechnical data artr'lar ertvuansite 2z✓see=5�at inforr,Iatian to the `� ,IpgOuw COUNTY PtssLtc tjFSLTH 3EEN�S <br />as it is avadable and at the same tithe d is provided to Tae ar Try mPMsQ=M I n I� <br />TYPE 06SERVICE �4UFSTEU: A) n 01 n - n I (z/ lf/,fti 1K — <br />COMMENTS: <br />APPROVED Sr. YV L.-. <br />A,rSVnMTO: 3 S uy <br />Date Service Completed [if already completedj: <br />Fee Amount= .• <br />Payment Type Invoice # <br />ExPLC `= l: DAT. �. <br />ESIPLOYf=a: DATA � <br />SGot�E .:. ..:: <br />Amount Paid (o—] , p Pa�rmer>f ate <br />Check 4 73 7' 1 Received By: <br />