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MAY-22-96 WED 14:10 K E CURTIS CONST CO INC FAX NC. 5102479592 P, 03 <br /> MvhY-21—r36 TUE 182;' PM K.E. CURT[m <m I 1<E> 7r 253 2595 P.t71 <br /> SERVICE REQUEST 011 80 613 R_wfsed 3123M <br /> r1htLitY to R RE/Coon 1p / IMNOLro s <br /> L FACILITY NW �NlFLS _ST—A7=5if�( <br /> tiILLIAG P+aIY Y y R <br /> SITE A➢DQESS "' --MA9VAA �. <br /> Citi ��7aC T6N ^„ , CA rip <br /> EsR/OP6RATOr: HILL(NG PARTY Y / M <br /> DELA _ PHONE 0i 1 ) � <br /> ADDRESS T _-- PHONE 02 4 _�!_.. <br /> CITY _ SiATE 21P, <br /> APH I -- Land Use A;ppliesitesin 6 -- T <br /> 004 Dist Least tam Coda <br /> - J <br /> CONTUmul Maur <br /> SERVICE RE4UESTOR t�n_t..iQ,'rms &Pis BILLIKG PART�P+ py Y / N <br /> ens PUME 01 <br /> RAILIw6 ADom ss t, a &-16 [..OI's��� l� � I" r <br /> GTYsiATt_ CA zIP � <br /> BILLING AClAiihla.EaG KMTE i, the iuidersl9led owner, operator or agent Or same, ackpWtedge that alt site ardor project specific, <br /> 04/END hourly chaOes associattd with this faellity or activity wflt bt IDAW4 to the party identified as the BILLING PARTY an <br /> Page i of this form. <br /> 1 also eertifY that I have prepared this application and that the work to Ik perfornad Ml be dant [M aeeordwWo with ail Sul <br /> JMUIM COIATY Urdinence Comet AM Stardards, state am Federal laws. <br /> AMWA)IM SICBATURE I�, <br /> Title: Data, _r^� <br /> AUTHORitATIOY TO RELEASE IHFORitattaMa in addition to tkC tj$me, When applfeabte, 1, the mmr, operator or agent of samB, of <br /> the property toeated at the abort site address hereby 8uth0ri2e tha rotoase of arty end all result4, jeotoOntcat data andJar <br /> eriviramentaUs[te assestlrmi fafareatla►to SRH XKCU[N MMTY PUBLIC KEALTK G9IYICES eWIRORMNYAL HEALTH DIYICION as soon ao <br /> 1t Jr, available aTd at the same Sime it is provided to 010 or W representative. <br /> Nature of cervica Requeatt Service Coda <br /> A59iomel to ET>altaYec R Date <br /> Dote Larwiee emplotod —A further Action RMIred; Y ! e PROGRAM ELEM"I _ <br /> Fay lynnuns Amwz* Paid DaM Of Payment Paymtmt Type Receipt R Ceeck f Rez.rd 6lt <br /> UR]T Gt[ _/_1 <br />