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SITE MITIGATION ACKNOWLEDGMENT/REQUEST FOR SERVICES FORM <br /> SITE INFORMATION SRN JOA COUNTY . PUBLIC HEALTH SERVICES/ENVIRONMENTA! HEALTH DIVISION` <br /> ITE NAME THER LEAD AGENCY <br /> S _ , • AGENCY CONTACT ,�/ �,,` <br /> DRESS pyglE � 'Y <br /> APN # <br /> ITT <br /> 7 <br /> BILLING / RESPONSIBLE PA INFORMATION IP 5✓ <br /> AME p/y <br /> (LING ADDRESS P.O. BOX 95 <br /> oll <br /> 1 TY ESCALON <br /> TATE ✓ CA Ip 95320 <br /> ONTACT NAME ROBERT M. BRAyTON <br /> HONE V,11209) 838-7388 <br /> PROPERTY OWNER/OPERATOR <br /> FAME �' HONE <br /> DRESS S <br /> Tr TATE IP <br /> CLIENT INFORMATION (IF DIF RENT FROM OWNER/OPERATOR) <br /> I <br /> AME HONE <br /> DRESS <br /> ITY TATE Ip <br /> X950 <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 ANDIOR 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 /> p <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 /> I,. <br /> AME ROBERT M. :,"BRAYTON S# <br /> IGNATURE ATE /4 ' f <br /> komPANY C.T. BRAYTON SON INC_ ITLE ✓ PRESIDENT <br /> PAGE ONE OF W <br /> 89.007(IV)12/90BILFRMI2 <br /> EH 29 01 <br /> ' �r <br />