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SERVICE REQUEST <br /> SERVICE REQUEST <br /> FACILITY ID» 0 �'��� <br /> Type of Business or Property �or� BIwNG PARTY 9--,5 <br /> OWNERIOPERATORl_py�� �OY iG, <br /> ILr J Q i-F Z <br /> ov -v--s �- o `^ S�V � 2 3 - <br /> FACatTY NAME l Ov S r 0 tA -�-✓ <br /> 1qw - <br /> groaMw" <br /> SITE ADDRESSS <br /> $trMt XvMW � r <br /> Mailing Address (If Different from Site Address) � - ZIP . <br /> G' STATE ` A <br /> LAND USEAPPI:CAMN» <br /> �` : J 1.• AYH» <br /> PHONE»1 LOCAMnCME . <br /> ( ) BOS DISTRICT <br /> Oct. <br /> PHONE»2 <br /> CONTRAC CR 1 SERVICE REQUESTOR -11p+G PARi1f <br /> REQUESTOR r S � s •• 4 <br /> L lz�V <br /> BUSINESS NAME <br /> L o,.6 o ` S ' Q FAz: <br /> MAluNG ADDRESS !Itr, 7t <br /> P. 6. 6 oX Z 6 21 o STATE ()(c. x' 7 3 -2 <br /> '�s Hass cwrnr,operator cc authorized aSe.-: .f same,a�wledge that al s� r 4'or prcied speafc <br /> BILLING ACKNOWLEDGEMENT: 1.the undersigned PmPOM cc r?h MM Pro1�ac acVity will be tK7. "me ort-r t smess as idena6ec x�:^ <br /> Pueuc HEALTH SERVICES t4vRuN rtN'AL HEALTH CNWN hourly — <br /> n acx>udance with all Swti.:.wlw ;r'Y Ordu�ar>ce Cedes :.3 SaTc and <br /> I also certify that I have prepared this appriMbOn and 7tai Me work=ee;e -e= !�bQ; <br /> o�,. c.o�4sC ,.t-mow y s t�.� of <br /> FEDERAL laws. <br /> :wTE: <br /> APPUCANT'SGKAiURP: <br /> OTHER AUfli0R ED AGENT <br /> PRCPErRTY 113USLNESS OWNER ❑ OPERATOR I MANAi c <br /> tl APR-CJx's nor:.;y►c PARr�.prod d xrdrortatlon to Lip is na.rd rifle A ;V 3 <br /> AUTHORIZATION TO RELEASE INFORMATION:When app5C -''e.L',e--w a operat°r cf CISpr°party 1=12C="e ober s:'-§addnsss.hereby a4—.)o=7 8 releesa of <br /> any and all resufts,geotechnical data anJ(or eny4wr tientallsite assess.—'ert r="=cii to ft SAN JaOUx COUNTY PUBLIC`:-.TH SEPAM:=.wIRONrENTAt HEAL;_r.S;GN aS SOW <br /> as it is available and at the same time it is provided to me or my repre5er=.a <br /> MYlVIE <br /> 7YPEOFSERVICEREQUESTED: ��1C7 l � 0 RECEIVEC <br /> cQwMEM: 0 C T - 4 2000 <br /> SAN JOAQWP <br /> PUBLIC HEALTH <br /> .'KNMENTAL H�.-- <br /> INSPECTOR'S SIGNATURE: comTRALTOR'S SKNATURE: <br /> APPROVED BY: A <br /> 1 l >:: 2�`1 DAT=_ <br /> ASSIGNED TO: V�� Ew-.0YEE#: 2G DATE: <br /> Date Service Completed (If 2[Mdy comple SERVICE CODE: aj*jLr� -PIE- <br /> 31 <br /> 3 <br /> Fee Amount Amount Paid Payment Date _lG <br /> r <br /> Payment Type Invoice 9 Received By. <br />