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06/27/2001 13:57 <br />20946833 <br />FIFTH FLOOR <br />SERVICE REQUEST <br />PAGE 05 <br />_ WN I I'WL 1 UK 1 <br />81"G PARTY 0 <br />ReaUEsroR <br />P. y2►LC-S <br />PttoNE # E"• <br />13US114@SS NAME TIZI A t!(LE E -M V 112W M OJTAL, 1 &IC- • � [� �7jD 2 � <br />NWUNGADDRESS 25,25 Y`/ BURBAN4 13L-ub • g% <br />COY 5 WK 3 AM ILL STATE tl- ZIP <br />BILLING ACKNOWLEDGEM'cNT:1, the undersigned property or business owner, operator or authorized agent of same, adtrtoude+rq <br />e that all ' iW anchor p ojea sperm <br />PUsuC HEALTH SgAVICES ENVIPMM ENTAL HFgTH omsioN hourly dtarges associated %it bhts projectCr activity wi0 be bitted b ma or my business as idenlifted an this=. <br />Codes Slzndartts STAT-. and <br />I also certify that I have prepared this appkatian and that the work to be perfommd ,4 be done in aooardance with all SAN JCAWIN CWNTY Orlin <br />Fr:oE�L taws. <br />APPUCANT SIGNATURE <br />FFZQPVkt/SUSMSSONNER ❑ CKRATORIMMAGER 13 O&HmAtTtt'14Rff®AG"cNr <br />1' )it(c <br />ffAPK=N7isoatSn81I)NGPA_�Aroofcfwtlro»SonisSi�"isrOgU d <br />AUTHORIZATION TO R EASE INFORMATION: N7ten appEmble,1, the owneror operator of the property boated at the above s'ta address, hereby autt-arae the relea<O of <br />arty and all results, geotechnical data arts W enviranmeat S11e zsse sateot Information to the SAN JMMLN COUNTY PUBLIC HEALTli <br />SERVIC<5 EfMRONhtENiAL H;v Tr flnnsta+ as soon <br />as it is avadabte and at the same time lis provided to me ormy reprwAntative• <br />TYPE aFSEIMCEREQUESTED: n n rj „ 1 Q� 1 //� w V 1t7 1LY w J44/;, <br />CoMMENTs: <br />APPROvED EY: <br />AsslcNEn TD: <br />Date Service Completed (if already completed)' <br />Fee Amount <br />Payment Type Invoice <br />CaNTRA=ft': <br />EmPLOY>= <br />Amount Paid <br />Check 4 <br />DATA — <br />SEtzvlcECot�e'.:. ..;.;: PIE <br />P�aymertt ate <br />Received ay: <br />