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SERVICERE4i M • <br />type or ousmess or rropeety <br />+ FACILITY IDU SERVICE REQUEST tl <br />(A>%^ -1C hnt'e%ACP- �Iro-se <br />PHONEN �• <br />OWNER OPERATOR <br />BILLING PARTY 0 <br />Kkrumt; Moms <br />FAX # <br />FActrry Nue <br />4AA, re I S 2 . <br />—t*.* It. —o S <br />t <br />Sn ADDRESS <br />\A( C $ G -V lxl ' <br />S 31r.•tNwr6•r <br />btW*@ <br />Stroolf—• <br />TYP• <br />Su111 <br />Mailing Address tit Different from Site Addressl <br />CtTy <br />�JaC <br />STAT[ ZIP <br />C 2S7 <br />PHONE lit Eir• <br />APN t <br />LANG Use APPLICATION 4 <br />(job .3� -SC 13 ' <br />PHONE>X2 Err. <br />BQS-DISTAIGT <br />LOCA VWCODE• <br />CONTRACTOR / SERVICE REQUfSTOR <br />R€OUESTOR Bum PART 0 <br />0 e,&11 --,as a S. <br />BUsmusNAME <br />PHONEN �• <br />Kkrumt; Moms <br />FAX # <br />ro o i—iZLA <br />4AA, re I S 2 . <br />CITY TATE Zip <br />t <br />BILLING ACKNOWLEDGEMENT; i, the undorsi nod property or business owner, operator or authorized agent of same, acknowledge that all site and/or project spedre <br />PUBLIC HEALTH SE VKCS ENVmoNAtt:NrALI• MTH OmStoN hourly charges as.00aled with this projector activity will be billed tomo or my business a.. identified en this- torn. <br />I also cavity that d have prepared this applimLon and Owl the week to be 9eeton=4 will be done in accordance with all SAN 10AOUw Couttrr Ord nano Codes- Standards, STATE and <br />FEam taws. <br />APPLICANT SIGNATURE DATE: --11 <br />PROP M- TY/BUSwcss ER OPERAIORIMANAGER 0 OnlLRAUTHOtIZEOAGENT ❑ &,V S i Coe <br />IrAPPtZ WrJS raft patrvC PAM proof or au1Wr3doe to sign it faquirvd Vile <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of tic property tooled at M above site address, hereby aulhorize the release o <br />any and AU teauits, gcoteethnrGll data and/or environmanlaVa'lo msesurcnl intimation to the SMjQAOUut C KMTY PUBLIC I{oL nh SElty u EWzOWENTAL REACT" Dr retcH as soot <br />as it is avaigabie and at the same lime it 4 provided to me or my representative. <br />TYPE OF SEmnCE REQUESTED: <br />COMMEHrs: <br />WISPECTOR-s bIGXATURB: COhlTRACTOR'S SIGNATURE: <br />APPnov€o oT:. EMPLOYEE It: DATE: <br />= ASSiItitirn TU: EMPLOYEE Il; DATt;; <br />Date Service Compieted (if already completed):SFItvICECODE: F ( E: - . <br />Fix Amount: Z C ( .>� Amatlnt Nd Payment Date <br />Payment Typc Invoice R' Check 0 Received By: <br />