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E MITIGATION ACKNOWLEDGMENT/REQUEST FOR Sr 'ES FOR14 <br /> SAN JOA*W-A COUNTY PUBLIC HEALTH SERVICES/ENVIRONMErwwmC HEALTH DI <br /> SITE INFORMATION <br /> THER LEAD AGENCY <br /> SITE NAME /) 'o S AGENCY CONTACT /N// /Q <br /> /�T <br /> 7 PHONE ;?0?g 6 P 37 <br /> 3 3 t? 3 8 Nd /I/leo !� <br /> ORESS APN $ /O <br /> 37x7 3ffs9 AvLc4 rf-a( <br /> Irr Sl44e-k-+o-i, CALIF. IP <br /> RECEIVED <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> RAhl <br /> �wul IT <br /> PUBLIC HEALTH SERVICES <br /> AME 6,v,el,,,vQ, y` la c. ENVIRONMENTAL HEALTH DIVISION <br /> (LING ADDRESS L{057 vr--f <br /> ITY con Coe-et STATE CA IP I / Y_S�2(7 <br /> ONTACT NAME Sly HONES/0 7r^a 3Q7 <br /> PROPERTY OWNER/OPERATOR (4g;/-O) 0007 - <br /> AME +e- 2 d G10 , HONE <br /> DDRESS <br /> ITYcFa TATE C,4 IP 95P2 <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> AME4eu.sty-- NSc4 Cao a.S HONE 1 yJ S 7 7- /.e p <br /> DRESS j3AS,.k p <br /> ITY , Lours TATE MO IP 6 3/!d' <br /> Zq 50 <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT S e, <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 AS SOON AS IT IS AVAILABLE AND AT THE SAME TIPSE 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/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 M,Ke, IAJv'a su <br /> iGNATURE ATEIOMPANY I Grdw4w Iiet- `e-4a. 4 S/7C ITLE <br /> 89-007(IV)12/90BILFRMI2 <br /> EH 29 01 <br /> r <br />