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Nov- 18-98 12 :44P P . O3 <br /> SITE MITIGATION ACIIIOAEDGMENT/REDUEST FOR SERVICES FORM <br /> SAN )CAOL'IN COUNTY - PUBLIC HEALTH SERYICES/ENVIRONMENTAL HEALTH 01L'ISION <br /> SITE INFORMATION <br /> THER LEAD AGENCY <br /> SITE NAME HS <br /> AGENCY CONTACT <br /> " � PHONE <br /> DRESS <br /> APN f <br /> ITY �Ip <br /> I <br /> BILLING ! RESPONSIBLE PARTY INFORMATION {✓n, ` / <br /> ��G G <br /> ILIAC ADDRESSC� �S<7/I.� <br /> ;ITT Vf"f]V ��Jr'I�- IT- TATE L.�'j- :P �v y^j r'V <br /> NTACT HANE r,�/ L�l�l� �--/'��vFG�L� NONE '�(� �J�7 <br /> PROPERTY O)NER/CPERATOR <br /> FE 1 S1= �/�Q S v G NONE <br /> rIDRESS I v {� ') <br /> TY s .T/ ...C.F:S� TATE <br /> CLIENT INFORMATION (:F DIFFERENT FROM OWNER,CPERATOR) <br /> ANE HGNE <br /> DRESS <br /> ITT TATE :P <br /> AUTHORIZATION TD RELEASE/SILL34G ACYMCWLEDGEMENT <br /> I, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, OF THE PROPERTY LOCATED AT THE ABOVE SITE ADDRESS HERESY <br /> AUTHORIZE THE RELEASE OF ANY AND ALL ANALYTICAL RESULTS, GEOTECHMICAL DATA AND/OR ENVIRCNNENTAL/SITE ASSESSMENT INFCRMATION TO <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION AS SOG4 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, ACSNCWLEDGE THAT ALL SITE AND/OR PROJECT SPECIFIC <br /> PNS/EHD HOURLY CHARGES ASSCCIATEO WITH THIS ACTIVITY WILL BE BILLED TO THE PARTY IDENTIFIED AECVE AS THE "RESPONSIBLE PAATY". <br /> APPLICANT'S NAME, TITLE, SIGNATURE/DATE <br /> ME ';t 71 /'Z k',1� �z74�.J �L <br /> , , <br /> SIGNATURE <br /> TITLE C�N�.�D i ,E,�F� DATE <br /> PAGE CNE OF TWO <br /> 89.007(IV)121908ILFRM',2 <br />