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SITEDATION ACKNOWLEDGMENT/REQUEST FOR SERVICE <br /> SAN JOAQUIN 0Y - PUBLIC HEALTH SERVICES/ENVIRONMENTAL N DIVISION <br /> SITE INFORMATION THER LEAD AGENCY DHS <br /> i <br /> AGENCY CONTACT DOL19 O'Neal P <br /> ITE NAME Kearney - KPF <br /> PHONE (916) 855-7748 � <br /> APII N <br /> DRESS 1624 E. Alpine Avenue <br /> IP 95205 <br /> ITY <br /> Stockton, California <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME HARGIS t ASSOCIATES, INC' <br /> (LING ADDRESS 2222 South DObson Road, suite 401 <br /> TATEAZ IP 85202 <br /> ITY <br /> - Mesa <br /> HOME (602) 345-0888 <br /> 'ONTACT NAME Lynda MaMS <br /> PROPERTY OWNER/OPERATOR <br /> HONE (209) 464-8381 <br /> AME Kearney - )PF <br /> DRESS 1624 E. Alpine Avenue <br /> TATE CA PIP 1 9 5 2.0 5 <br /> ITY Stockton <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> HONE <br /> LAME <br /> OGRESS <br /> TATE IP <br /> TY <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 INFOR14ATION 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 /> OR AGENT OF SAME, ACKNOWLEDGE THAT ALL SITE AND/OR PROJECT SPECIFIC <br /> ADDITIONALLY, 1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, <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 /> � r— _- SN <br /> TAME Q-t- / �- ' L" <br /> ATE <br /> IGNATURE J111 ) <br /> OMPANY <br /> • OCT 07 1991 <br /> 89-007(IV)12/9081LFRM12 <br /> LNVIRONMFPTTAL WFAUff �%a5C ,mac cA �p76. <br />