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SIT.TIGATION ACKNOWLEDGMENT/REQUEST FOR SERVICOORM <br /> SAN JOAQUIN COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> SITE INFORMATION <br /> OTHER LEAD AGENCY �JGj1ZWQCZ <br /> ITE NAME [�u//'� / / /� / ��rt AGENCY CONTACT �•r�o Old Vo ows e- <br /> (J�$ �l p/ 1 `- 7`a�- (n1 PHONE A. -A,�-.J(c¢7 <br /> DDRESS N 1 I f A' 4 Oo-Y � eOa.d' APN # ,Z S-7 -0 3- /o <br /> z ml e SowtL. o Ir Pa � ernes <br /> ITY m0.„ cc� IP <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME �QGITiC GQS aLj ELeG+T�c. Grote4Ay <br /> I L[NG ADDRESS 31y— rfo!'t� W, A Lane SLII+e. Ido U 1 <br /> ITY WOLIVILL+ C1-r-e - TATE CA [P g4Sg g <br /> ONTACT NAME Mr. £r-neS+- F- Lee HONE ($ID) 746-47-42- <br /> PROPERTY OWNER/OPERATOR <br /> AME {PG-is - &as'pmjLte+1ono.4 S-lora De HONE (S1�>�4fe-42-47- <br /> DDRESS 3-15 kortL. W: c-} Lane. 5": w- l7o <br /> ITY Waln,-- Cree.�_ TATE I CAl IP I 44598 <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> AME HONE <br /> DDRESS <br /> ITY TATE IP <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT <br /> 1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, OF THE PROPERTY LOCATED AT THE ABOVE SITE ADDRESS HEREBY <br /> AUTHORIZE THE RELEASE OF ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS <br /> PROVIDED TO ME OR MY REPRESENTATIVE. <br /> ADDITIONALLY, 1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, ACKNOWLEDGE THAT ALL SITE AND/OR PROJECT SPECIFIC <br /> PHS/EHD HOURLY CHARGES ASSOCIATED WITH THIS ACTIVITY WILL BE BILLED TO THE PARTY IDENTIFIED ABOVE AS THE "RESPONSIBLE PARTY". <br /> APPLICANT'S NAME, TITLE, SIGNATURE/DATE <br /> AME 1r/2ll S# <br /> IGNATURE a elol /� c n ATE /Q-29- 97- <br /> OMPANY � ,fE-7P�ink.�aA✓CCo�OGifay �NiCCS ITLE �Co/0 FG /�o. ¢EBS <br /> J 1 <br /> 89-007(IV)12/90BILFRMI2 A- <br />