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T�-7iiais`r �ie,,p'�i�i' �ri4i•i, .,_._.., .., .., r, ����� r. a <br /> I t>rRVlcr, REQUEST p CMH 00 61) Revfeed 6/23/03 <br /> PACILITY ID Y RECQR0 ID Y �� (J LNWICd if , <br /> (ACILItt NAAtL 1/•7► <br /> CAL— <br /> AM <br /> AL— I I V IILLIMO PARTY Y /�N <br /> SITe Aw9T <br /> CITY � .1�' CA IIP <br /> YR <br /> OYNER/OPATOR USA rn +`0LlMC- Czr(a_ _ 41LUNY PARTY w T��u, <br /> DBA r PHONE 01 ; �a )p� <br /> AIMlRE1:S 3 (� �t 7 tYl l�G I m 02 lQA I-f fa-- O �g <br /> t , <br /> CITY J�3FiOIAn{� �, -- STATE SQA ZIP zo j <br /> APH P IF,a .nd Uso Apptio■ticn Y T <br /> ago Dist ►oast l.el_Coda <br /> LYAt)RACTLtt ewd/or <br /> SERVICE kEQU20OR AtQ PM�k4!?,� �• n PILLINQ PARTY <br /> I alawwwM�* <br /> DBA IO--t,jAAtr7 <br /> zg..:�� 1 _ PNDNE /S f��T u�,,ppr )y,��•.K= 7 <br /> aAILINO ADOW&I" .10r E _ 4!1!: 5a I-•t PAX Y 1=15+� t )�'7'� OC <br /> CITY P¢ N,A STATE ZIP <br /> SILLI116 AMOMMLEDGENENT1 1, the undemiprwd owner, spsrstor or pent of smnc, eckrroRledae Chet e(I eita ardor project specific <br /> PILO/SHO hourly charge# associated Kith this facility or activity wiLt be biLLed to the party Identlfled ar the PILLING PARTY CA , <br /> Page t of title torn/. (l`/1►ryyEA'NN7 <br /> I also cartlfy that I rave prepared this opp(lcatlon and that the work to be performed NTLI be done in aeaardsnea�riIl'TRAP <br /> )OAOUIN COLINTY Ordinance Ccdae and 4tanidiarde; State and Federal laws. OCT 2 0 1997 - <br /> APPLICANT'S 4IONATURE ----s.--- PUBLIC HEALTH SERVICESENVIgONMENTAL HEALTH DIVISION <br /> Title: r0 Dotal Z'L� <br /> AUTHORIZATION TO ttLEASS INFORNATIaII In addition to tTN above, when aWticabl■, 1, the b~, operator or agent of same, of <br /> the property Located at tho above site addrou hereby wahorlte the reLaase of Ori'/ and ati rasutts, Qsotachnlcal data and/ar <br /> erniromml tat/Bits asaesoaont Informtfon to BAN =QUIN COUNTY PUBLIC HEALTH 1"VICR2 ENVIAONPKNTAL MALIN DIVISION as loon u <br /> It to available grid at the sane tial It 'Ie prayfuad tom W Qtr repreaentatiVo. <br /> Nature of Service Rv%m&t: F, Barvlta� /L'.Cade/" b _..p � <br /> Assigned to A:1G_ 1 l h %v R(-1 � Rnpltyta Y ��� _ ofte / a , -L_L_ <br /> Date service Completed J Y further Action ROWIredt rL_r / a PROGRAM EIA001 T <br /> Pea y>}s)t p Aaaun tld O Date of Payment Paynrnt Type Receipt N Check Y ReM 4y•' <br /> s its I�/ (�,/ swv / ��. ACCT _/^.J..._.� WIT CLK <br /> IX <br />