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,06/27/2001 13:57 2094683103 FIFTH FLOOR <br />,xavbLv R�Qu=sr <br />PAGE 05 <br />CONTRACTORISERVICE REQU) SIUK <br />REAUESTOR BUM PARTY 0 <br />Pi�MG—tfF Yv2Li�5 - <br />BUSINESSNAME — _ - PHONE# ftT. <br />/R,RTIUc c c"�c/eo,✓.vE�Jn4G , /i✓c # 8�{0- 7026 <br />iWWuNGADMssF�� <br />W. 3ur/<jL vD <br />cTrr BuR-A/RaJA:�. STATE 0 j Zug <br />BILLING ACKNOWLEDGEMCN% 1, the uade*ned property or business owner operator Or authorized agent of same. adowle6ge mat d srx and/or pr*ct sped <br />Pt>Sf.fC HEALTHSafi' M ENVfAONMENTAL HEALTH UMMM hOOdy charges assodaieC hYltlt ft proleci Or activty wit b0 billed to me or my business as identified on this `Arm. <br />1 also certify that I have prepared this appOcaton and tat the work to be performed 4 be done in mance with all SM JCAQUN CWNN Ordina= Codas. Standardt STATE and <br />FEDERALim. 7 <br />APPUCANT SIGNATURE: ` �—DATE! —/ `% —2 <br />PRor5k1Y/t3usn SSOWNM 0 OPERATORIMAWER 13 0M5tAVrM0RMMA cGWr <br />ffArmcArrrisoafNO 8J0c9A prtof UdWia ca to sibk+xgriicad rifle <br />Atl7 HORIZ4T1dN 70 RELEASE 1NF3RMA11ON: When app6mbie,1, the ovmeror operator of the property located at the above site address, hereby authorize the release of <br />any and at results, geotechnkal data m1for a liftnMaMysite zs3e=me0t information to the SArt JOACUL.4 CoLn" PU&C HEALTH SERvrcis ENVIROW MAL HEALTH tirvMM as soon <br />a;. q gxenfc mnA attha came firneit is amvided to me arm repres8ntidm <br />