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sERVx',E REQUEST <br /> �Pe of uslnes; or Property FACILITY ID Z SFWCE REC GEST 9 <br /> 5 s �` icn/ Q 3 <br /> NER 1 OPERATOR_ BILLING PARTY a <br /> vtolo <br /> CLRYNAmE ��C r �+ C <br /> SRE A00RESS <br /> sa..rn•M+.. nr.cdan V ��i��lv J`� so-...h.... ns. s.,'.1 <br /> Nailing Addriss (II Otl/erent from Site Addre331 <br /> Oo i i} s j•r <br /> STATE /+ftl <br /> 1F40HE41 EAT- APN LANOUsEA�PucAnaN� <br /> b) - 63 a ��f 1�,�- <br /> 'Pone 92 ar• SOS OLSTRMT L,:w;AvoN COUE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> ZEVUESTOR BILLING PARTY <br /> PAO�- x�r��tr peso <br /> 3uStNESs NAnrE ��• C PHnNE x . ERT. <br /> Utz tNc Aoowi 5 - Fuc I - <br /> ���ll ISM. 5 i� b I y�83 <br /> :rl•r Mv nom-; STATE ✓1 TIP G <br /> ULUNG ACXNQWI,EDGEMENT: I, Ute undersigned property or business owner,operator or aothorhed sgent of isms• adutvwle0ge usat aft silo and/or project :peck <br /> 'VSLtC HEALM S£RVmCEs ElMRVNuENTAI HE+L T{Otvuton hourly dmarge3 assodatad wtO tha project vac"w,9 be billed to ma or my business as Idenuhd on this ivrm. <br /> also cartity that l have prepared tliz applkutlon am bat Ute work 10 be performed wig be done In;mxordance wO ad Su+.:eAous+CCXXTY OmIneme,Codes.Standards,SrArE and <br /> SDEPAL laws. <br /> PnJCANT SIGNATURE: p�f0 DATE 9-2-8 <br /> ROPERTY/BUSINESS OWNER G OKRATCn I MANAGER O OT1+ER Aunicm Eo ACEKr <br /> d Avnuewr 13 Ad 1W 8U.14GPRwrr p.00t of arrrAorfr,rforr ro sEpn d f l rl e <br /> ,UTNORIZATTON TO RELEASE INFORMATION:Wlxn avptic3ble,1,Ute owner or aporator of the property bomtea at the above site address,hereby aullmme the release of <br /> rry and aA results.geotechnical data and/or tnwrwunematlsle awessment hflarmadon�o Ume SAN Jv.OUw CoUNry Puw-oc HEALTH Seiv)cas ENVM c"-- (AL HEEV-TN OMWON a3 soon <br /> I it is available and at ume same dme it is provided to me or my n resemelive. <br /> E of SERnCE RE]UFSTED: � <br /> RECEIVE� <br /> OCT 2 01999 <br /> AN JOAJU, <br /> PUBLIC HEALTH S S <br /> E DIVISION <br /> 3P[CTOR'S SIGNATURE; COKMC A'S SIGNATURE: 2e;' <br /> 'PROVED 9Y: Ewtaym 2: Do\ Old <br /> ;SIGNED ro: 'i Et+atcyEE A: OATI <br /> ite Service Completed (t already campletedJ sairince CODE '2 PIE-P/E <br /> e Amount: Amount Paid Payment Date ` <br /> yme t Type Invoicex Checit A ( Received By <br />