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FROM TAIT SACRAMENTO 916 63S 2606 <br />41:1�lja"A�ilj <br />P. I <br />PACILITY NAM <br />y <br />SITE ADDRESS <br />122' L2 <br />CITY <br />a <br />z I <br />ERA70ft <br />BILLING PARTY <br />pffmE #1 j!l 6 k1l -t - <br />DSA <br />ADDRESS <br />x..1 <br />PHONE 92 C CA) 4P <br />mm", <br />MT W <br />V-flw"— <br />cuNTRACTOR mWorII <br />BILLING <br />PNWE #1 (-q- <br />DUA All I <br />MAILING ADDR - ESS FAX <br />CITY STATE C�a ZIP <br />qi�L= AcKiXWEDOEWNT.- 1, the undersigned owner, operatior or agent of sanle. acknowtedge that all site aWor project Specific <br />AVEHI) hourly charoes assatiated with this facW tity or activity wi It W bi I Lad to the party identified as the SULING PARTY on <br />Page I of thig form. <br />I also certify that I have prepared this apo ication and that the work to be perfotwW 4i L I be, done in accorclame with at I., SM <br />JWUIN COWTY Ordinance Codes aW Standards, Stbte and Pederat tows. <br />APPLICANT'S SIGNATURE z I — <br />AUTHMIZATIOM TD RELEASE IWANATICIN', In aeWition to the abq%m, when aMticabte, 1, the owner, Operator or awnt <br />The property located at the above site addres& heteby authorize the release of any mid all results. wtechnicat data and/or <br />etwiranwrital/site assessrwnt infomation to SU JCMIN CWNTY PU8LIC SEALTH SERVICES ENVIRONMENTAL HEALTH D.IVISIUN as sow 65 - <br />it is avaitabte and fit the awk- tine it is provided to we or my rtpresentative. <br />vats Service Ccupketed <br />service Ccde <br />Date <br />