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06/27/2001 13:57 2094683433 <br />FIFTH FLOOR <br />SERVICE REQUM <br />PAGE 05 <br />CONTRACTOR! SERVICE REGUESTOR <br />REOUESTOR BIUMG PAM <br />BUSINESS NAME Y�RO PHONE(Q q40-70AQ <br />M IL # tYr <br />u <br />MmuNG ADORES - - - - - - - - _ F" *b D r l n , L. 4,) 9 <br />Cfrr - _ STATE LP <br />13ILLING ACKNOWLEDGMENT: t, the undersgned property or business owner, operator or authodwd agent of same, advwhedge that all site and/or project specaw <br />PMUC HEALTH SgWMS Exvtwc MENTA. HEALTH DNocN houdy charges associated with this pmjed or acdyky will be biVed to ma or my business as identified an this krm- <br />I aw cei fy that I have prepared this appfiwtien and that the work to be performed 4 be done in ac=dance with all SAN ,>CAMI.N CwKN Ordinance Codes, Standards. STATE and <br />FEDERAL laws, e q� n, 1_ v <br />APPucAxT Slaw=Rf:: V DATE: / O► y <br />pPO�` tY I SUBMS$ 0AWR 0 OPEERATORI KWUGEa� OTHM AuTmO tM AG _!rr 0 > /u`l. � r� <br />1f APPtaurrisnatfND P Prp00f2UdWd-.180fifosi9nkf&Vk d Tiffe <br />AUTHORIZATION i0 RELEASE INFORMATION: When applicable, I, the owner or operatnr of the property bcamd at the above sae address. hereby authorize the release of <br />any and aU fesUICS, geotechnical data andfor wrihnmenwUsite assessmeat information to the SAN jMQUw COUNTY pusLic HEALTti Sa Rv n ENMFtM rENTAL HEALTH OMSlON as soon <br />as t is available and at the same lime tis provided to me army rep=Qrmdve. — <br />TYPE OFSERAcER=Esro; a — <br />COMMENTS:,µ��V"Or- <br />1� r <br />0,ra COUN <br />,1J�� S <br />r, <br />AF?Rowu BY: jl //� ESt1n OY� #: 'U IN= <br />ASSIGNEDTO: EmpLOYF—=#: ` DATE <br />Date Service Completed (rf already completed): Su&gm GoDE ' : ,:�'.: '� PIE: �() <br />Fee Amount Amount Paid �, T? ! Payment Date '10 �, a 3 <br />Payment Type r Invoice # Check 4 2, 29 D D C 6 .1;,1.- Received By: <br />