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i 12-26-1996 12.22PM FROM P. 4 <br /> SERVICE REGMT CEN 00 613 Et o3w 8/0/0 <br /> FACILITY 10 d RECORD ID dIMYq;CE e <br /> FACILITY MAA -- —_ __-- __ 8ILLING PARTY `. Y / N <br /> SITE ADDRESS <br /> CITY CA ZIP <br /> OWOWOPERAT" BILLING PARTY Y- / N <br /> 013A Mwe An <br /> ADDRESS <br /> CITY STATE ZIP <br /> " 0 toed Use JN*iantian d <br /> l B4S Dist Lacs#ion Dade <br /> CWTUCTM and/or <br /> SWICERE9lJE5T0R EELLtle- <br /> 10MAIS <br /> PARTY Y / N <br /> OBA Di C_) <br /> MAILING ADDRESS FAX d t }� <br /> CITY __^^ — STATE ZIP <br /> BILLING ACKNM&EOGEMNTc 1, the underslgned owner, ap>:retor or agent of sauce, sckrowkedge that ell site and/or project specific <br /> pa/60 howty charges asanoiated with thio facility or activity mill be bitted to the party idertifiod as the %HI 1 1B PARTY on ' <br /> Page l of this form_ <br /> I also certify that I have prepared this apptieation and that the m rk to be perfornred will be done in accordance with all SAN <br /> ,ioWIN CtlMrY Ordinance Codes tamdands, state and F ral tarns. <br /> APPLICWIS SIGNATTAiE: " <br /> Project 'Mann'-ge.-t;nv'. and Reg,. gate.12-26-96 <br /> T�tEe: <br /> MTHURIYATION TO RELEM INFORNATZM' In ad)9Slon to the above, Whin appticabte, I,�the owner, operator or agent of owe,,of. <br /> the property Located at the above site address hereby authorize the reteam of any and,atl results, geoteclrnicat date ani/o <br /> e1wirorvoentaUsite assammant information to SAN MAouIN CMKff PUBLIC MEAUR 8MVICES MVIRMMTAL HEALTH DIVISION ass,soon <br /> it is araitabte and at the sense time 1# is provided to nue or air' repre Wfttive., �, <br /> Nature of Service It "t Service Code <br /> Assigned to Dste._.��,J "�.•.�.. .� Ix' <br /> Date Service tompteted F Vurdter Action Required T / `N PROGRAM ELENEW <br /> Fee Amount Amount,Paid . Date of Payment Payment Type 8ecaipt B:�r Check P Recvd By <br /> �H <br /> 12-26-1996 12:19PM P.04 <br />