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SI._ AITIGATION ACKNOWLEDGMENT/REQUEST FOR SERVIL, r%" <br /> SAN JOAGUIN COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> SITE INFORMATION THER LEAD AGENCY <br /> !TE NAME AGENCY CONTACT <br /> C, a k 6r) it'- <br /> PHONE <br /> DRESSAPN # <br /> 2024 E. Cha2te2 G1a,y <br /> irY Stockton, CA.. 95205 PAYMENT IP 95205 <br /> BILLING ! RESPONSIBLE PARTY INFORMATION <br /> ,1 <br /> AME C ea t1c GIe e e, Inc SAN JOA LJlN r' ,.; <br /> L i <br /> ENVIRONMENTAL F,�l <br /> ILING ADDRESS 2024 C. Chaititea bla <br /> Lty <br /> iTYStockton 3TATE CA IP 95205 <br /> oNTACT NAME 8ichoee ?. Ciank 5HONE 209 462-7676 <br /> PROPERTY OWNER/OPERATOR <br /> EAME HOME <br /> 2000 E. Cfia.,zte2 Vac <br /> Stockton TATE IP <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> AME 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/Olt 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 Nichae-f /�. Clank s# <br /> i GNATURE ATE 2 r lang 9 1 <br /> OMPAHY C�a2k Glee Inc ITLE <br /> PAGE ONE OF TWO <br /> 89-007(IV)12/90BILFRMI2 <br /> EK 29 01 """" <br />