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allD <br /> SITE MITIGATION ACKNOWLP^ EOUEST FOR SERVI S ORM ,- <br /> SAN JOAQUIN COUNTY - PUBLIC HEA LId <br /> RVICES/ENVIRONMENTAL H L ZION q/ <br /> SITE INFORMATION ER LEAD AGENCY <br /> ITE NAMEF1700 <br /> der Truck AGENCY CONTACT <br /> PHONE <br /> DRESS N. Broadway APN a <br /> ITY Stockton IP 95205 <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME Ryder Truck <br /> (LING ADDRESS 3600 NW 82nd Avenue <br /> ITY Miami TATE FL IP 33166 <br /> oNTACT NAME Jim Spinnenweber HONE 305-593-4063 <br /> PROPERTY OWNER/OPERATOR <br /> 77 <br /> AME Ryder Truck HONE 305-593-4063 <br /> DRESS 3600 NW 82nd Avenue <br /> ITY Miami TATE FL IP 33166 <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> HONE <br /> IAME <br /> DRESS <br /> ITY TATE IP <br /> AUTHORIZATION TO RELEASE/BILLING 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/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 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/OR PROJECT SPECIFIC <br /> DHS/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 Patrick Galvin sk <br /> IGNATURE ATE G S' I� �� <br /> 6, <br /> OMPANY Environmental Science & Engineering, Inc. ITLE Senior Project Engineer <br /> consultant for Ryder PAGE ONE OF TWO <br /> 89.007(IV)12/90BILFRMI2 <br /> EH 2901 <br />