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YA <br />SERVICE R71mcrr <br />Type of Business or Property FACILITY 10 <br />SF-RVICE REQUEST; <br />OWNER/ OPERATOR <br />SILUNG PARTY p <br />FAciLrrY NAME Q / <br />StrE ADDRESS <br />T <br />v /0 <br />Mailing Address (If Different from Site Add.ress) <br />Ty" $�Y <br />Car <br />STATE ZIP <br />PHONE #1 APN 9 <br />( <br />LANo USFAPP=noN it <br />PHONE #2ltxr. <br />(JS Dtsrwcr . <br />LOCAMN CODE. <br />CONTRACTOR /SERAC <br />REQUESTOR <br />REQUI:sMOR <br />13wNc PAR7rJ�- <br />BUSINESSNAME <br />PHONE Fxr <br />hiAJLwG ADDR>r55 <br />FAX Z' <br />Crrr C�"'` f <br />STATE 1jp <br />BILLING ACKNOWLEDGEMENT: 1, the under4ned Property ar business owner; operiter <br />PUmx HEALTH SERVICES ErmRONMEN AL HEALTH Dm=N hourly dlarges associated with 04 project <br />or zuthor¢ed agent of same, admcwledge that ae site ar••dfor prvjed spec.,i <br />or activity W be billed to me or my business as iderrMed <br />on psis arm. <br />I also certify that I have prepared this appfxmdon and that the worts to be perhumed wig be done in <br />i=FERAL laws. <br />acxardance with an 5Ax J=w CCUNCY Ordmarxe Codes. Standards STATE arx <br />APPuasr SIGNATURE: <br />SATE <br />PROPERTY/ SUSwF= OMER ❑ OPERATOR 1 NWtAGER I] <br />AUTHORCED ACM ❑ <br />AAA-C-Wf4 Mtrg 0.r.MP—AMYpraot <br />Gf2UdA d=2(6rrtosrsprfsragvar9d iiUo <br />AUTHORIZATION TO RELEASE INFORMATION: When 2ppLcable,1. the owner or 0 peratui <br />any and all results_ geotechnical data and/or environmenaVshe a=,e=rnent information to the Sm <br />of the property located at the above site address• hereby authorize the rdease of <br />OAO,AN COUNT' Pu&jC HFALTH Sys ENMONMENTALHEAL`H Orv4-,CN as <br />as it is evadable and at the same time it is provided to me or my reprererrmtive. <br />soon <br />TYPE OF SERVICE REQUESTED: j <br />PAYi,viL�,, <br />2002 JL <br />COUNT), HEATH FNVIRONMEER�OS <br />i <br />HFAI TH DIVISION <br />EA <br />PROVED 8T: �% DATE. <br />J-2— <br />SIGNED TO: t C EUPLOYEEP DATE /0 <br />/// d Z <br />Date -Service Completed Of alr=dy completed): c� S�aZV=CoDe <br />Fee Amount' Amount Paid&7— <br />P! E- <br />�(" & 7 ....- Payment Date �D �� d <br />PaymerttType t/ lnvaice Check (i -7� _ K Received 8y f% <br />