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Nov- 18-98 12 :44P • P . 03 <br /> SITE MITIGATION ACKNOAEDGMENT/REQUEST FOR SERVICES FORM <br /> SITE INFORMATION SAN JCAOUIN COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> �? // THER LEAD AGENCY <br /> SITE NAME ,=5 ; ` ,� /y S'S�/t-7�}L/ b/')A`'J 97761VIJ AGENCY CONTACT <br /> PHONE <br /> DRESS �ffiE; r/(/L,� UJ�7•�/A4 L /'O�/:;/.� L/!'r/('�. <br /> APN R <br /> STY <br /> �Ip 01533 <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> E /} s E Laxs's . <br /> (LING ADDRESS .3��,� ET 64 S c.; Lam,!1 <br /> ITY Jf ri� r /�' � AtL (z l i- ' TATE CP� :p il Y Y <br /> XTACT NAME / L!-�l"�/�,Q ' �1'�l�f C%�'L� HONE 4oC3 '`J In-7 <br /> PROPERTY OWNER/OPERATOR <br /> E TSc Z46 <br /> CRESS1�4- V <br /> i TY S-4 ISTATE C/� <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNERICPERATOR) <br /> II <br /> ME f � XCNEDRESS <br /> TT TATE :P <br /> AUTHORIZATION TO RELEASEISILL14G 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/CR EXVIRCNKENTAL/SITE ASSESSMENT INFORMATION TO <br /> SAN JCAQUIM 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, 1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, ACKNOWLEDGE THAT ALL SITE AND/CR PROJECT SPECIFIC <br /> PHS/END 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 /> LAME <br /> o / <br /> IGNAi1.RE � / <br /> tTLE DATE <br /> PAGE ONE OF TWO <br /> 89-007(IV)12/9O81LFRM112 <br />