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Sr'l-..-IGATION ACKNOWLEDGMENT/REQUEST FOR SERVIL :M <br /> SAN JOAQUIN COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HrALTH DIVISION <br /> SITE INFORMATION <br /> THER LEAD AGENCY <br /> ITE NAME Blockbuster Video/Yellow Submarine AGENCY CONTACT <br /> PHONE <br /> %DDRESS / -" West Harding Way APN # <br /> U <br /> ITY1 �` VE�� <br /> IP <br /> Stockton, Ca. ,� <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME Village Properties <br /> AILING ADDRESS 703 Market St. <br /> San Francisco, Ca 94103 TATE I Ca IIP 1 94103 <br /> ONTACT NAME HONE 41 <br /> PROPERTY OWNER/OPERATOR <br /> SAME R. W Read ( HONE 510 <br /> DDRESS 40 Roble Ct <br /> ITY Berkeley TATE Ca IP <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> AME Eugene P. Tiscornia /1/ HONE 209-477-8794 <br /> DDRESS 7735 Caran Ave. <br /> "I TY Stockton ISTATE I Ca 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, I, 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 /J Cp�� /�u 1 'Y cP VQ S# <br /> l / <br /> I GNATURE / ATE s Q J <br /> CMPANY TITLE <br /> 89-007(IV)12/90BILFRMI2 <br />