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,y_11-1997 S,CCcr.l <br />sE0.YICE REOUESI <br />P. 2 <br />(EN 00 61) Revised 8/23/93 <br />INVOICE E <br />RECORD IDE <br />FACILITY 10 d e�2 _-3 1 CSC <br />FBLNG PARTY <br />FACILITY NANE '• <br />SITE ADDRESS 3 535 L a S CA ZIP 4 <br />CITY k <br />p �O'/��a�/ BILLING PARTY v <br />"ER/OPERATOR PNONE %1 (� . <br />GAS Sle <br />DBA PNaNE E2 C <br />ADDRESS STATE ZIP Q <br />f�'�� <br />//1!!L G Loeac ion CI yf� 11 WtiGn E SOS o15t <br />Lard Use App <br />W. i <br />BILLING PARTY <br />Y ! N <br />CONTRACTOR xd/or '��/)t���rC"SPiA <br />V((!/� PNONE EI ( �' <br />SERVICE REOUESTOR �( FAX !• <br />i! <br />DBAf'✓` CASi-/-) /'7�/!J('J <br />NAILING ADDRESS ZIP------- <br />STATE � <br />CITY viect 6pecif is <br />fir, operator or agent of same, acXrowled9e that ..:ell site _andlor IL <br />Witt be Sam. CO the party identified is the BILLING PARTY on <br />BILLING ACKNWLEDGENENT: i, the undjhiS 1PR 2 1 1Jr)/ <br />PN5/ENO hourly Charges a99mCiated with Ia19 facility Or ar,LIV1Ly f� JJ <br />Pape 1 of this <br />form. Nill be done in accordance with all SAN <br />lication and that the vork to ba pRrfO .._ <br />red this appL11crH DIV:. <br />I also cerci ty that 1 have � � Standards, <br />Febrral t° ziVVRONMENTR,LHEALTH DIVI - <br />JpAOU1N COUNTY OrdiMnpe COdeI // / . . <br />APPL ICON <br />T'S SIGNATURE <br />/"'Yti/� e: <br />�! %%/ a �xr operator or apart of sane• 04 <br />k�/ whet+ appl;cable. 1, cn or <br />TStle: r ults, yeotKhnical data s S <br />tion to the above• of any and ell es as som as <br />TO RELEASE INFORNATIONL In edd hereby authorize the release MI HEALTH DIV' <br />AUTHORIZATION ve site address PUBLIC NEALTN SERVICES ENVIRON <br />the PrWer y located °L the <br />ebo JOAtlJIN COUNTY <br />t information Lo SAN to � my representative. <br />envirorinIl/site assassman it is provide, Service Code <br />it Ss available oaf at the same time <br />Date r— <br />Nature of Service Request[ <br />Ewtvy <br />J2 /� U _ <br />+- <br />e PROGRAM ELM*' <br />1 N <br />AssigAed to S ction ReWlred: 0 ! <br />/ further A <br />laced _�! Recyd BY <br />Date Service Co^P ChecX E <br />PayMnt Type Receipt E' <br />Date Of Payment <br />Amxmt Paid <br />Fee ARCVht <br />!� Acer <br />_/�J� uNtr GLK <br />RExs <br />