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SITE,,_y;C.AT10N AC1O10WlFDGkENT/REQUEST FOR SERVIt�S'�S <br /> SITE INFORMATION <br /> SAN OAQUIN COUNTY EB/ENVIROWENTAL HEALTH- PUBLIC HEALTH SERVIC <br /> .- <br /> '+HAGENCY <br /> tTE NAME outheast Cornet of Arch 6 Kingsley Roads AGENCY CONTACT <br /> PHCNE <br /> DRESS 3568 East Arch Road AAb 0 <br /> 181-122-0 <br /> tTY Stockton (San oaquin County) Il' <br /> BILLING / RESPONSIBLE PARTY INFTION <br /> AME salbi & C ang Asacciates <br /> !LING ADDRESS 151 Link oad, <br /> JTY Cordelia TATI CA 1P 94585 <br /> ONTACT HAMS Long Chin P HCNI 707-864-2020 <br /> PROPIRTT MMER/OPERATOR <br /> A>�E Obed W. Hill & ildred 0. Hill 209-931-1709 <br /> ORISS 5723 Cherokee L ne <br /> ITY Stockton TATECA <br /> IP <br /> CLIENT INFORMATION (If DIFFERENT fROM OWNER/OPERATOR) <br /> E Sarghausen Consulting Engineers, Inc. HOW 916-348-3057 <br /> ORIss 4612 Roseville load, 'Suite 103 <br /> ITY North Highlands TAT D CA IP 95660 <br /> AUTHORIZATION TO RILIASE/SILLINO ACKNWILIDGINgHT <br /> I, THE; UNDERSIGNED OWNER, OPERATM, CLIENT, CR AGENT OF Wa, OF THE PROPERTY LOCATED WINE ABOVE SITE ADDRESS H¢REBY - - <br /> AUTHORIZE THE RELEASE OF ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA ANO/OR EWVIAONMINTAI/SITE ASSISSMUT INFORMATION TO <br /> SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAM9 TIME IT 13 <br /> PROVIDED TO HE OR MY RIPRESINTAT VE. <br /> ADDITIONALLY, I, THE UNDER31GNED OWNER OPERATOR, CLI€NT, OR AGENT OF SAME, ACKNOWI.EOGE.THAT ALL SITE AND/OR PROJECT SPECIFIC <br /> PWS/EHD HOURLY CHARGES ASSOCIATE WITH TNI= ACTIVITY WILL B(IBILLED TO TH9 PARTY tDINTIFIED AOM As THR "RESMSIBLI; PARTY". <br /> APPLICANT'S NAME, TITLE, SIONATUR OATS <br /> AMI Long Ching so <br /> 10NAtURE �. AIR 6/27/91 <br /> PANT Halbi & Chang As tciates ITIS Senior Engineer <br /> PAGE ONE OF TWO <br /> 84.007(IV)12/900tLFR912 <br /> EH Z9 91 <br /> VI : bI E f-i <br />