Laserfiche WebLink
} <br /> SITE,&IGATION ACKNOWLEDGMENT/REQUEST FOR SERVICE° 0.H <br /> SAN JOAQUIN TY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL TN DIVISION <br /> SITE INFORMATION <br /> _T <br /> ER LEAD AGENCY <br /> ITE NAME AGENCY LON TALI <br /> eabka Distributing Co. <br /> PHONE <br /> DDRESS 1245 W. Weber Ave . APH # <br /> .ITY Stockton IP 95201 <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME Bank of Stockton <br /> AILING ADDRESS BOX 1110 <br /> ITY Stockton TATE CA IP 952QI <br /> :ONTACT NAME John Urittia HONE <br /> PROPERTY OWNER/OPERATOR <br /> LAME HONE <br /> DDRESS <br /> 'ITY ISTATE I IP <br /> CLIENT INFORMATION (IF DIFFERENT FRO14 OWNER/OPERATOR) <br /> TAME HONE <br /> DDP.ESS <br /> 'ITY IS 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, I, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, ACKNOWLEDGE THAT ALL SITE AND/OR PROJECT SPECIFIC <br /> PHS/EMD 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 /> TAME SAMK OF S-MCkL-CoK) SN �i <br /> IGNR4E -�_:6 �(�enT 2 P�AJ�� p I �,.{ ATE - �JdV 'LOMPAA LCO� TITLEfl. ' £� IN,(p�� <br /> 89-007(IV)12/90STLFRM12 <br />