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ql-I vl <br /> SITE M17IGATIMIiCX110YLEDOMNT/REQUEST FOR SERVICES FORM <br /> SAN JOAQUIN COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISIC1. <br /> ITE INFCRMATIO( HER LEAD AGENCY <br /> AGENCY CONTACT <br /> ITE NAME <br /> ST. JOSEPH' S MEDICAL CENTER OF STOCKTON PxallE <br /> -, .,, <br /> DRESS EIF <br /> �df n I�G� S`�' r• '' IAPN i '; <br /> 'ITY STOCKTON, CNIA ` W RO '1FNTAL H : ?C N 95aY3' <br /> TILLING / RESPONSIBLE PARTY INFORMATION <br /> E ST. JOSEPH'S MEDICAL CENTER OF STOCKTON <br /> (LING ADDRESS 1800 N. CALIFORNIA STREET, P. O. BOX 213008 - <br /> NTY STOCKTON ATE CA tP 95213-900_= <br /> xONE 209/467-6308 <br /> TACT NAME MR. JERRY COTTON = <br /> PROPERTY OWNER/OPERATOR <br /> E ST. JOSEPH' S MEDICAL CENTER OF STOCKTON xaNE 209/467-6308 <br /> DRESS 1800 N. CALIFORNIA STREET, P.O. BOX 213008 <br /> ATE CA IP 95213-9008 <br /> ITY STOCKTON <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> HONE <br /> DRESS <br /> TATE IP <br /> ITT <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/SIVE ASSESSMENT INFORMATION TO <br /> f MC V f <br /> cALiH DTVI"`-OM ^.S SC..4 S <br /> " S IT IS AVAi LA.4LE .��.. <br /> , <br /> .A2i JOA�'IN COUNTY P'JSLIC HcE,.P SERVICE,, EMSIRCNMS4TAL .. _ - <br /> PROVIDED TO ME OR MY REPRESENTATIVE. <br /> OPERATOR, CLIENT, OR AGENT OF SAME, ACKNOWLEDGE THAT ALL SITE AND/OR PROJECT SPECIFIC <br /> ADDITIONALLY, I, THE UNDERSIGNED OWNER, <br /> BE BILLED TO THE PARTY IDENTIFIED ABOVE AS THE "RESPONSIBLE PARTY". <br /> PHS/EHD HOURLY CHARGES ASSOCIATED WITH THIS ACTIVITY WILL <br /> APPLICANT'S NNE, TITLE, SIGNATURE/DATE <br /> E BILL GARRISON <br /> IG URE <br /> DATE <br /> ITLEDe dT dile Ilt N'13T18 eT P18Rt 0 eTdt 1085 <br /> PAGE ONE OF TWO <br /> B9.007(IV)12/90D1LFRMT2 . <br />