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'3-2014 1 K STOP 12?98325307 T 871904 P.1f1 <br /> 1406:070 � 20'1904 p.1 <br /> FE��7J6;i1ouiN COIIN7'Y EwmoNMENTALRFALTa DEPAIYrMLNT <br /> R NMENTA SERVICE REQUEST <br /> laiVIType al BuslltessfdE��1„"`' FAMLt1T IDS SERVICE REQUEST P <br /> �12vb6 q1�� <br /> OM@eR I OPMATOR <br /> ' <br /> ET — <br /> FACLm RAK_, <br /> StTEAtl01iE�5 <br /> �. v ' � Al <br /> HOME Or MAIUNO ADDREGS fit DtlFetrnt*tM Site Ad dre=) <br /> Seat ilun�bsr <br /> CITY STATE LP <br /> P►�0tse S t GT F-7S LAmo lice Aowls Tow a <br /> f ) <br /> PWM82 SOS DIVINCTT <br /> COOK <br /> CONTRACTOR I SERVICE RE2asra� <br /> R TOR <br /> 13ueot "fJ1 dw �. <br /> HOME orMmmme APDRW PAX# <br /> CITY /.<j STATE J-- <br /> BLLI, NC. AC.fCPiQMLEDG�Nt: t, the undersigned Property or business owner,,operator or salhorisW agent of same, <br /> acknowledge that all site and/or project specific 1U%,ntc mrwrAL 14rAl,rt7 D(inARTMWr hourly ehargas Wilminted with this projoct <br /> or activity will be billed to we or my business as identified on this forth. <br /> I also ocnify that I have prgmmd this appl' tat the work to be formed rr 111 be done in accordance with al)SAN JOAQt;IN <br /> C.cxiNrY Ondtrmnca Codes,Mandards,, E d <br /> APPIACAmrs SIGNATURE: DAIV <br /> PAorzkyv/Ruairmwow�sR❑ 4rest&Totti wtxAC4n oi"mAuTiioxmxoACBNT 0 <br /> Jf APP1JCAA,7 fs not*he&L 4V PARTY proof of avl inrizOax ioRigh is rega&ed Tfrf! <br /> &UT'NORiZATION_M 1tEU..A%,:(.ORM�ATION:When applicable,1,the oweer or operator or the property Located at the <br /> abovo site addswrs, hereby authorim the release of any and all reauhs, geotechnical dam MAW environrtlentaysits assessment <br /> information to the SAN J0.%QUrN OXWrY ENVIRONMENTAL I ILALTH LXPARTM Off as soon as it is available and at thnsante time it is <br /> providod to me or my reptewntstive. 'gY149 <br /> rYP@ QF 30tvtCE RtxltlEaiPD: VED <br /> 00MW*T3:r_ n CJ "f e x oanncy a 173 Jnai g5A2g0l1 <br /> 4 ICSj�� , � � Pump NNMEEA <br /> Ely <br /> Accerttzo Br. EMPtATeE S: DALE <br /> A'miano To: PJtPtATtiEm DA at: <br /> Odle Service CoMptased (W atnedy eomppnod): St ffm Cope. lc P/E Z <br /> Fee Amon tl: ? c' Arr Paid -3Payment bite, -3115-1)4 <br /> Payment Type invoices ,2 S(b GbCheep r g 0� Received Sy: <br /> EMD 4b-024 25n DIS 1 ct SR FORMA{Golden ROM <br /> REVISED 11/1712003 f� l I <br />