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SITE MITIGATION ACKNOWLEDGMENT/REQUEST FOR SERVICES FORM <br /> SAN JOAQUIN COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> SITE INFORMATION <br /> ITE NAME THER LEAD AGENCY A�0-}wp OlyJGlJopfpwskQl�z <br /> AGENCY CONTACT�u/67 /2ls �� dM /r- �� /fbq <br /> PHONE <br /> DDRESS N7 ISokt�. of A' + OoLy 4 perrl,'gaj APN # <br /> L yell e IrPor <br /> ITYM I _ IPS <br /> fbk"ti. L57-off.2- <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME IBLE0.cj'f,c &4_% L%%j G'CG: C Cz <br /> meoLoky -(TaS-PrDlucwn*SoroUt- <br /> AILING ADDRESS 31S VCM`+^ W; evie, SuITf- 1-10 <br /> ITY wa.lvlu+ Cf-ce.K 3TATE G/4 IP q+Sq 8 <br /> ONTACT NAME tYl t-- ErneS-V F Lee. HONE `$ID) 2 9-7 <br /> PROPERTY OWNER/OPERATOR -1 <br /> AME P&£ £ - 6-aS-pfbj"c-- iona+j S-�Dra DQ HONE <br /> %DDRESS 3-7S' r ortL IA). e.+ Lane 5,.Ae. 170 <br /> ITYWaLlA +- CrCC-� TATE Ga IP <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 !S AVAILABLE AND AT THE SAME TIME IT IS <br /> PROVIDED TO ME OR MY REPRESENTATIVE. <br /> ADDITIONALLY, I, 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 / rrel/ S- klk'/ man S# <br /> IGNATURE � ,5_. ATE 1 /O Z9- 92- <br /> T I T L E <br /> LTITLE &Co%3 iS R& Alo. 48&8 <br /> v <br /> 89-007(IV)12/90BILFRMI2 _ <br /> a- 1 , �5 S c� <br />