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SITTIGATION ACKNOWLEDGMENT/REQUEST FOR SERVIC RM <br /> SAN JOAOUIN9NTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL�TH DIVISION <br /> SITE INFORMATION <br /> OTHER LEAD AGENCY Central Valley Re oval <br /> Brd <br /> ITE NAME AGENCY CONTACT James Brathovde <br /> Delta' Truck Sales/Former Surface Impoundment <br /> PHONE (916) 361-5738 <br /> DDRESS 3535 Cherokee Road RECEIVED <br /> APN # <br /> 3655 CAAL&Lax- <br /> Stockton, California "1" 95208 <br /> ry ENVIRONMENTAL HEALTH 'P <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME Delta TIuck Sales <br /> (LING ADDRESS P.O. Box 8068 <br /> !TY Stockton, TATE CA IP 95208 <br /> ONTACT NAME Darrell Smith HONE (209) 466-4161 <br /> PROPERTY OWNER/OPERATOR <br /> AME Same as above HONE <br /> DRESS <br /> ITY TATE I IP <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> AME Same as above HONE <br /> DRESS <br /> ITY 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, TITLE, SIIGGNATURE/D/ATTE�y1 <br /> AMEIC /�L� J i'/ �Y�/ S# <br /> 1GNATURE �/ / t, C ATE �/26 9/ <br /> DOMPANY ,D/.LUtK S/pL CJ ITLE yI �4 //-RGG��O GNT <br /> 89-007(IV)12/90BILFRMI2 <br />