Laserfiche WebLink
SITE MITIGATION ACKNOWLEDGMENT/REQUEST FOR SERVICES FORM <br /> SAN JOAQUIN COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> SITE INFORMATION <br /> THER LEAD AGENCY <br /> ITE NAME Brookside Development AGENCY CONTACT <br /> PHONE <br /> DDRESS 2271 Wes t March Lane APN # <br /> lTY Stockton, California, 95209 ZIP <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME Clark Well, Inc. <br /> AILING ADDRESS 2024 East Charter Way <br /> ITY Stockton, California 95205 TATE IP <br /> 'ONTACT NAME George M. Clark Michael R. Clark BONE 209 462-7676 <br /> PROPERTY OWNER/OPERATOR <br /> AME Grupe Development - Northern California HONE 209 473-6155 <br /> DDRESS 2271 West March Lane <br /> ITYStockton TATE CA, kIP 20 <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> AME HONE <br /> DDRESS <br /> [TY 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 /> PHS/EHD HOURLY CHARGES ASSOCIATED WITH THIS ACTIVITY WILL BE BILLED TO THE PARTY IDENTIFIED ABOVE AS THE "RESPONSIBLE PARTY". <br /> APPLICANT'S NAME, T TLE, SIGNATURE/DATE <br /> DAME Ge �re M. C E��z <br /> S# 548-70-2106 <br /> IGNATURE ATE 4 D e c 91 <br /> - vl�~Vh V, <br /> OMPANY Clark Well, C. TITLE Sec-Tres <br /> 89-007(IV)12/90BILFRMI2 <br /> 1 <br />