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05/29/1990 03:03 7073742663 NDE ENVIRONMENTAL PAGE 04 <br /> 552VICE REQUEST cnm 00 613 Revised 0123n3 <br /> FACILITY NNE <br /> d 1'111 1140 <br /> $I TE ADDRESS <br /> CITY <br /> ONNES110PERATOR <br /> alr .e <br /> PHONE 01 <br /> BEA <br /> ADDRESS 46k PHO16 02 <br /> CITY ke STATE ZIP <br /> APH 9 —Land Use Appticatilon # <br /> BOB Dist I I Location Coda <br /> coNTRAcTcR mWor <br /> REQUES7011 <br /> pmw #I <br /> FAX 0 <br /> MILING ADDRESS <br /> CITYZ STATE _j�� ZIP <br /> . ez <br /> BILLIKra AcKWULEDGEMENT: 1, the umiersigned owner, operator or went of sain, @dufflWIodV that all it andlor project specific <br /> PHS/END hourly charges associated with this facility or activity mitt he billed to the party Identified as Che 9ILLtNQ PARTY an <br /> pop I of this form. <br /> I ata* certify that I have prepared this oprptleation and that the wwk to be performed mitt be dam in socor4ance With Bit SAM <br /> JORWIN COUNTY Ordinance codes tmWarded State and F cat taws. <br /> APPLICANT'S SIGNATURE <br /> Title: Data* <br /> AUT HMIZATION TO RELEASE INF 01U%T1QHz In addition to the abvm, when spipticable. I, the omr, operator or agent of sow, of <br /> the property located at the &0ve site address hereby authorize the release of wW w-d stL results, Quat 6 <br /> anvirommentailaits assessment info ti to SAN JOAQ)IN C=TV PUBLIC HEALT I1 SERVICES ENVIRONMENTAL REALY V as n6 <br /> it go available ® at the same time it is provided to so or my r0prOBOtali <br /> VI. <br /> Service <br /> ode <br /> Nature of Service ReWeat, T <br /> ure of Ser <br /> a'm'm <br /> Na <br /> to Employee 4 Onto <br /> Data Service Completed Further Ration RoWired: T I N PROGIM ELEMENT <br /> Fee Amount Amount Paid you of pryment payment Type Reaelpt check 0 Recvd By <br /> ACCT UNIT CLIC <br />