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10/21/2002 <br />2094683433 <br />is <br />CONTRACTOR! SERVICE REOUESTOR <br />BILUNG tNG ACKFIOWLEDGEbfe�, I. the undersigned Property Or business owner, apentor or authottzed agent of same' ecknovledge that a! sem and/or Project specfic <br />HFe uV Dtvvlr.WN t ourty t,ages assocated with tis project or acVity will be billed to me or my business as i Aftd an <br />R=HEv.TH Seavx Es this lcrm <br />in aaardance with au Su+JOna1e7 t+n Codes SFti7E a <br />nd <br />I also W* fat I have prepared this applicati0a and that bhe wrnh -o be performed Wil be done Stattdatds <br />FEDERAL taws. DATE: <br />APAltCA1fFS"ATVP.E: r/ <br />OPEPwtcR i MANAGER ❑ r -fa -d-&2601 A� Btr � <br />PROP6RT'rI8U5J4F.550WNFJt � Fitts <br />tf APRr-W is nd theaU5R over proof cf wtlra4afkn toslgn is rpu nd tuthetiaa the mleasa of <br />tJRiZAT10N TO RELk99 INFOR6WT !: When applicable. 4 the Oster or operator of the property forested at the Wwve site address, �bY <br />AUto the SAN J6Atx3iN GCi81SY PiJBUC HEALS1i $ERVlcFS ENVrROtYMENI� HUL.H DN MON a5 soon <br />any and art result. geoteohnxzl dam ant'lor env6onmerxaits to assessment info =Wn <br />as it a evadable and at the same tlme a is pravided to me er my repres8nt3d"- <br />TYPE of SERVICZ REQUESTED: <br />APPRMED81". - -� <br />ASStt3NED T0: <br />Date Setvica Completed (R already GDf"PItted): <br />pee Amount 2-- i <br />PaymentType Invoice <br />CME: <br />Paymont Date <br />P1E 'L <br />It 1141ri <br />Rewired W. � <br />o.t <br />NOV 13 2002 <br />ENVIRONMENT HEALTH <br />PERMIT/SERVICES' <br />