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11-30-1999 10 : 39AM FROM <br />1 Type of 8Usina9e. or Prap4rtp <br />I OPjRATOR <br />\_, <br />3trEADdiR@S5 \ �, "^ <br />f J tS Arae! Nomas '` n <br />1 Mailing Address (if Different from Site Address) <br />SERVICE !REQUEST <br />FACIUTY V » SETACE REQUEST r <br />se � .. . <br />tL "All <br />T <br />9une i <br />�nY STATE ` zip <br />t �3 <br />PHONS 91 W. ! ARN 9 LAao Use APPLCATION 9 <br />FHOHrc #I SOS DMT=T ' LOCATIOP! CDoc--i J 7 1 -1 <br />i <br />CONTRACTOR / SERVICE REQUESTOR <br />SILLINQ Ag6N2WLEDG6MFN7' t. the undemigned property or husiness owner, operator or ac.4omad agent of sante, w*nowledge that stl site andlor project ,poor c <br />Pusuc i-A&YM 81" <br />eS EWNYMNTAL HEAi.Tt1 DMSVNt howdy Ch$1903 gated win this pmjed oe acdvity wit to W.W b me or my hoiness as idendk-i hn this- tam. <br />t also rtiry 7dat t hove preps tris appkation and that the work to be parformed wit be done h aarthdavx wlih all SAtt oAfwMl CouNT'f Ordinance codes. Spa..7daMs. STAT= arr <br />APPLICANT SmuruR$ DATE: 6 1 t .¢ ' 1/ <br />PRBPE,�TYtBUSINESS OPERATOR AGER OrweRAcmoR=AGw <br />yrs Its a pooParxrtfiorisatla+rtvsipn.srnr,� r�Fre <br />AUTHORIZATION TO RELEASEI—FOR51ATION* When acp 4he awry or oaeratur of Tit prapany kxaw at the above sato address hereby aMortze the Please of <br />any and ao mutts, 9"t" hnicol dole andior anvironmerit Ltite assenTftwo "nfan 40oa to the Sit+ JOAr7tn.4 C4'% wry PvwX HRALr" SGRvY_'ES E9,4RCNmSNTAL HEALM CIMS* J as soar <br />as 0 is available and at the name lima d b Provided to me or ns y repmernative, <br />TYPE of SERV[CE RomiesTerr. <br />COt[AiiNi'S: <br />PAI= m r-- N. <br />'iECEIV : <br />Nov 1,9 09 <br />ENVrfiQt4re1ENTAL 4� T�EWLStOAI <br />! INSP=ECTOR'S SIGNATJRE: CONTRACTOR'S SI MaT MI: <br />j APPROVED EY: EHPLOYEE I DATF, <br />i ASSIGNED TO: f , EMPLOYEE s DATE: <br />Data Service Cempfe±ed (If aiready compleWd): SERME CODE: L <br />Fee Amount: { maunt Paid 1� f Payment Date <br />Payment Type invoice # Check s % G' �t I Received 9Y: I <br />