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SIT <br /> ON <br /> EST FOR <br /> 14 IL <br /> SAN JOAGUINECOUNTYATIPUBLICC HIALTTHMSERVICES/ENVIRONMENTALEHEALTH DIVISION <br /> SITE INFORMATION q1-� �J,f <br /> THER LE N Y `i f[� <br /> ITE NAME <br /> United Parcel Service AGENCY CONTACT <br /> P <br /> DRESS HONE <br /> 1532 North Broadway APN # �L?b <br /> ITT <br /> Stockton, California IP <br /> s� 95205 <br /> BILLING / RESPONSIBLE PARTY INFO€�tAT1ON <br /> ERMEPatrick <br /> ted Parcel Service ' I ,h�.. ' <br /> 0 Shore Drive 'l� C T <br /> t Sacramento TATE CA <br /> IP 95591 <br /> Browne HONE 191 ,51 373-400 <br /> PROPERTY OWNER/OPERATOR <br /> AME United Parcel Service <br /> HONE 356-3313 <br /> DRESS 8455 Jackson Road <br /> ITY Sacramento ISTATE CA IP 95826 <br /> CLIENT INFORMATION (IF DIFFERENT FROM ]ER/OPERATOR) <br /> AME N/A IIOHE <br /> DRESS <br /> ITY TATE IP <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 JOAGUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT ;C <br /> PROVIDED TO ME OR MY REPRESENTATIVE. <br /> ADDITIONALLY, 1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, ACKNOWLEDGE THAT ALL SITE AHD/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 /> DAME j Patrick Browne S# <br /> I GNATUR TQ./'L— ATE 10/8/91 <br /> OMPANY United Parcel Service ITLE District Plant Engineer <br /> 89-007(IV)12/9O8ILFRM72 <br /> Nw- <br />