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SfRvlte RFOUEST (EH 00 61) Revised a/Z3ijyj <br />FACILITY ID M /n /� Q RECCRD db MI - q--- - - INVOIE 4 1 O 3J <br />:tit':LITY NAME <br />Walton <br />Engineering 9168731172 P.02 <br />a� - <br />R�,rnav�l <br />°►� I bC&"* toy* <br />SfRvlte RFOUEST (EH 00 61) Revised a/Z3ijyj <br />FACILITY ID M /n /� Q RECCRD db MI - q--- - - INVOIE 4 1 O 3J <br />:tit':LITY NAME <br />-q fjl� <br />L7 f / � O <br />Receipt R <br />BILLING PARTY <br />Y / <br />SITE ADDRess <br />l a2 / /V. <br />i j 0!217 a/ <br />.3 2- -6 <br />C �, <br />CITY _-�- <br />S C. c <br />P 9s 10 7 <br />CA ZI x <br />---�—��-� <br />2E'L 6 1996 <br />inE fvayRArpR <br />/}1 / �� <br />/ <br />fj /2 VC 10 <br />_PI <br />NC PARTY <br />Y / N <br />06A <br />Cyv��c 5 /o,�__ <br />/i%fir'1C��5 2/?G <br />.,AUG <br />WirpwN <br />ADDRESS <br />6) Q <br />X y <br />PWONE 02 <br />-- <br />CITY I- rz C yr 0 V�T STATE q zip 9 J ! ?L <br />avN Y maw land Use Applitetian R - -- -_ 7�� <br />..WTRAC7CR and/or <br />r$:R'JlGC REOUESTOR %I Cx- --- --- BILLING PARTY Y /0 <br />043A U7 ,'tPtin rzh V LCNt ���'_—......_ - vNpHE01 <br />NAIL! K�, ADDRESS 8,.? Ot l,s L��E' �(%�/C- FAX v .3 -�L3 Ll <br />CITY �Ur_5Z: �(1G/Q i/iril O STA -E Cil_ ZIP - 5 C"F1 <br />FILL:NC ACKNOWLEDGEMENT: d, the undersigned ower, gtxrator or agent of same, acknoutedge that al: site andfor project SpeCifiC <br />,=Ws/?:;D hourly charges associated with this facility or activity w;tt be billed to th_., warty idlcnrifietl as the BILLING PARTY on <br />Page i of this form. (a LAj nLrre- / opcY-C,+C, YzF ibicd ccLo0—, i Milli nc ?&T -+y <br />i otso certify that i have prepared s apptication and that tele work to be performed will be done in accordance with all SAN <br />1c�Aol1IN CCU+ITY ordinance code and L rda, State and Federal takL. <br />j ` YMENII <br />APPLICANT'S SIGNATURE /w � 4. C <br />f : Ie:. L.I Q �.. Date: AUG 2 6 1996 <br />AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, whet+ appticabie, I, the 9wr.-r, operator or ir�41d )"JPN6 ;.JUWT� <br />the property located at the dbove site address hereby authorize the release of any and at( results, geotL_ ch/�kn�r�I��eEt�I�a��ditSERVICES <br />envirormentat/site assessment information to IAM JOAWIN COUNTY RIBLIC HEALTR SERVICES eWVIRONMENTAt HEAL H Dril( ON"4�"TH DIVIS(()ys <br />i- aveitabte and at the sane time it is provided to me or my representative. <br />Natvra of Service Request: 1 Q w&- mn� <br />Assigned to ^LaskflC: J4, Employee 0 � _^ <br />Det* Service Conpteted / Further Action Required: Y / V <br />Service Code <br />Date <br />PROGRAM <br />Fee Amount <br />Amount Paid Date of Payment <br />Payment Type <br />Receipt R <br />check N <br />ReCvd By <br />l � 0 <br />8'' 2 b i6 <br />ee <br />.3 2- -6 <br />C �, <br />