Laserfiche WebLink
SITE MITIGATION ACKNOWLEDGMENT/REWES7 '- <br /> SITE INFORMATION JOAQUIN COUNTY - APNa 17 <br /> -- <br /> SITE <br /> HEALTH SERVICES/EN SERVICES FORM <br /> NMENTAL HEALTH DIVISION <br /> ITE NAME <br /> THE R LEAD AGENCY <br /> Mildred DeVencenzi (owner) <br /> AGENCY CCN TACT <br /> DRESS <br /> PHONE <br /> 21167 N. Tretheway Rd. <br /> APl1 # <br /> IT <br /> 4campo, Calif. <br /> BILLING / RESPONSIBLE PARTYIP <br /> INFORMATION <br /> AME Mildred DeVencenzi <br /> (LING ADDRESS 12667 E. Eight Mile Rd. <br /> ITY Stockton <br /> Calif. <br /> TATE <br /> -ONTACT NAME Bob Hesseltine IP 95205 <br /> PROPERTY OWNER/OPERATOR HONE <br /> 20 4-� 4S <br /> AME <br /> A � A <br /> DRESS <br /> ITY N 18721HONE <br /> Jack Tone Rd, 20 2 - 817 <br /> Lockeford Calif. <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER W TATE <br /> /OPERATOR) TP X2-37 <br /> AME <br /> Mildred DeVencenzi <br /> DRESS 1226 E. HONE <br /> Ei ht Mile Rd. (202)931-348C, <br /> ITY Sto kton <br /> Calif. <br /> iA TE IP <br /> 20 <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 INFORMATIC <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME I <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 SPECII <br /> PMS/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 /> IA,ME <br /> IGNATURE -�'/� / S# X 2_ <br /> CMPANY ATE ��1,/,.,/01 <br /> Res onsible Part <br /> 89-007(IV)12/90BILFRMI2 _ <br /> i <br />