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M-•-, 28 01 05:40p <br />i <br />Typc 0(2Usincss or Property <br />C4:> V% .t C rn i c 11% c e. <br />OWHEP.I OPERATOR <br />Ra j C �01 <br />T nk—Tek Env. Corp. <br />SFRvicE REOUM <br />FACILITY 10 :3 <br />eA-o0A�9/5 <br />(W) 446-6152 M` _ p. 4 <br />SERVICE REQUEST k *-, <br />8u,UUC PARTY Q <br />FAciurT 1:AME <br />Suit r <br />er;atfir:g tidatcsz (if Urticront from Site Address) <br />CRY <br />`J c STATE Lr <br />G Z—r <br />PNONt �i Ln_ ApN » LAR13 USE APvUGtTIOR 9 <br />YNOIiE E1 Q EST - <br />ilk= " „ I.00AT10N.cobE D$ D lS <br />Yr: <br />CONTRACTOR! SFAvtCF RFOl PMP <br />REOUMOR Bulk PMTY D <br />aoilt:ES5 NAME <br />PNOHFp rfr_ <br />M++n arc Anaruss <br />FAx 4 <br />GRY TATE Zr� <br />✓ <br />BILLING ACKIJOWLCDGr-- M[NT: 1, Inc undcmgncd properr/ or buslnts owner, opm491' of avtho&cd 49cnt of same. QQkAu-Wgc Oat all .1ha andlor prvied ,pmrc <br />FUtkIC F(Ent TFr SF1ty CC5 ErrvNrvrruFniuHCAr Ttr Onnsrvr+ hovrh ehsr9e: as:aoaled with OL, pea{odor actktTY wig lx billed to rao or trey business i. identified en tht- Torn <br />13130 cettity M l have prcpamd this app&mt oa and that the wch to tK pcAorr7ii:d wil be done in XWMW= with alt SNI JOAGUw CWHTY On3'n&KO Cndcs, Sranduds, STATE JnG <br />FEaEfut laws. <br />ArrUCANT SlawcYunC: DATc..��o <br />pace, trrIMuc.ss n ti OPCPAIOR/MW40CR Q 0n1CnAt)mciurCbac4Nr co, 5 r C, <br />rrA"It wr 1s na un 12u Am" vovl ur,uthmcjr w+ ro Sian rr�+r r11a <br />AUT H0R1TAT'1ON TO RILE SIE INFORMATION: YWhen applicotc.1. utc owncrat opcntorof Nc 0f0PCnY bCalcd at L7c aDove site Iddres;, hereby aumarU c Ptc relcabe o <br />any and aQ rcauh. gealcehniCuk 3313 andi(K cnvirotxncsuaVate a-.scsxnanl inSvmwl+vn to the $.wJonqum CWHTlr PuouC HOLtt c SOrAcLs t wj,;uroutrrw 11c►ur DNetpe as seor <br />3s it Is av393We and 31 the sane 6me it c providcd to me or my repmsentalivc. <br />Tyr E OP SCrrncc RroucsT[o: , r -c- h) ly �,kM <br />G C CLIC cj-n-C. � 3'�•-T <br />'?ENT <br />;= rzt;f tVECJ <br />App 1 n ZQ01 <br />SANJC,_�- <br />PUBLIC HEAL] riSEijv/ CES <br />NVIRnNMFNT,1I �F; �r,� <br />INsr�clDn's StGNnaire: <br />:ASSIGtICOdO: ��Jj�� � <br />Da(c Service ComPkIed r( already camptct0j: <br />FCC AMOunt <br />Payrncr;t Typc invoice 8 <br />COMACTOR'S St ,PfLi gk: <br />- - EtPtoYEt.:11: OATS: <br />EASPIOTI-611: C C� DATE: <br />' -- SFINICECODC: i'�. <br />ATnoun[ Fid Payment 03(c <br />ChcckC ��r��S <br />PfE: r� <br />Received 4y: �� <br />