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SMITIGATION ACKNOWLEDGMENT/REQUEST FOR SERVI'ePA"ORM <br /> SAN JOAQUIN COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> SITE INFORMATION <br /> OTHER LEAD AGENCY <br /> ITE NAME r AGENCY CONTACT <br /> per r�-r L PL-LIM r5 ► tj� <br /> PHONE <br /> DDRESSv J 5 zj APN # <br /> ITY <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME C S <br /> AILING ADDRESS i z) ) 03 a J,- <br /> ITY TATE I P �f — t7 <br /> ONTACT NAME S l�l 1� s 13-! L—)=—, Z HONE 0-0 �F (o(p 1-47 7 3 <br /> PROPERTY OWNER/OPERATOR <br /> AME y� C�1�� 1L� HONE <br /> DRESS <br /> ITY TATE (JD IP 41 cS"7�[� 1 <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> AME ONE <br /> DDRESS <br /> p. i <br /> ITY 2 logo <br /> ATE [P <br /> PUBLIC <br /> ENVIRONI`AENIAL',IEhr .!I�i�oi3i0N <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT <br /> I, 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 ASSOON 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 ANO/OR PROJECT SPECIFIC <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 /> AME <br /> IGNATURE ATE ! a j q /9 Z <br /> OMAANY ITLE <br /> 89.007(IV)12/90BiLFRM12 <br /> Is <br /> p. <br />