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SIT:-t'ITIGATION ACKNOWLEDGMENT/REQUEST FOR SERVICES-mRM <br /> SAN JOAQUIN COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> SITE INFORMATION <br /> THER LEAD AGENCY <br /> ITE NAME - AGENCY CONTACT,] <br /> PHONE <br /> DDRESS g7,(, ! � � G� /`---� APN # <br /> ITY � IP 9�✓ <br /> BILLING / RESPONSIBLE PART INFORMATION G <br /> AME TRIPLE E PRODUCE CORP. <br /> P.O. BOX 239 <br /> %ILING ADDRESS <br /> TRACY <br /> IiY % TATE CA IP 95378 <br /> ONTACT NAME AG� HONE <br /> PROPERTY OWNER/OPERATOR 3 <br /> AME <br /> HONE <br /> DDRESS <br /> ITY IS TATE IP <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> 1AME IP <br /> HONE <br /> DRESS <br /> ITY TATE IP <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT y� <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 /> S'N 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, TITLE, SIGNATURE/DATE <br /> AME H `J. ESFO , MES PRESIDENT s <br /> 1GNATURE ' - ATE <br /> 1lAR 1 7 1992 <br /> romPANY TRIPLE E P DUCE CORP. ?iT,,E PRESIDENT` <br /> PAGE ONE OF r 'f lAk 9 � 1992 <br /> EINvIRONMEN `Al. HEAJ.."I'Fj <br /> 89-007(1V)12/90BILFRM12 (' Rilliiii;,L+,v,;,t: , <br /> EH 29 01 — <br /> �4 <br />