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�� 'yep"..'�` '� �.."•� "r� 'y, �':� � n��` •� --N <br /> • I <br /> SITE HITICATION ACKNOWLEDGMENT/REQUEST FOR SERVICES FORM <br /> SAN JCAOUIH COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> SITE INFCRMATICN <br /> THER LEAD AGENCY <br /> "E <br /> NAME AGENCY CONTACT <br /> f ARD Savior Statim N7. 760 PHONE <br /> RDORf55APN tl <br /> 2 5 SaU (J]G[C3M LdTYY? <br /> 1 T Y rod; IP 95240 <br /> SILLING / RESPONSIBLE PARTY INFORMATION <br /> AME AKD Pn dz OaTp2ny <br /> IL1NG ADDRESS P.O. $3C 5811 <br /> 1 ITY Sall Mfftm -TATE� CM)A% IP 94402 <br /> CNTACI NAME (hrk C.`dTIT['1 P HONE{ 415-571-2434 <br /> PROPERTY CWHER/OPERATOR <br /> ANE AIM F3llIcts HONE I 415-571-2434 <br /> I.DDRESS P.O. BM 5811 <br /> 17Y L SaT1 Mlbap TATE I C71 IP I qW2 <br /> CLIENT INFORMATICH CIF DIFFERENT FRCT4 OWNER/OPERATM) <br /> .ME pq2ied , Inc. HONE 916452-2901 <br /> DDRESS 4191 Fier 7mFtedSLitieD& E <br /> ITY SaCraTED TATE [P 95826 <br /> AUTHCRIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT <br /> 1, THE UNDERSIGNED OUNER, OPERATOR, CL:SNT, CR AGENT OF SANE, OF THE PROPERTY LOCATED AT THE ABOVE SITE ADDRESS HEREBY <br /> AUTHORIZE THE RELEASE OF ANY AND ALL ANALYTICAL RESULTS, GEOTECHYICAL DATA AI1D/CR EIIVIRCXHENTAL/SITE ASSESSMENT INFOR14ATICH TO <br /> SAN JOAQUIN CCUNIY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION AS SW!i AS IT IS AVAILABLE AND AT THE SAME TINE IT IS <br /> PROVIDED TO M£ OR MY REPRESENTATIVE. <br /> ADDITICNALLY, I, THE UNDERSIGNED CWNER, OPERATOR, CLIENT, 0.1 AGENT OF SANE, ACKNOWLEDGE THAT ALL SITE AHD/OR PROJECT SPECIFIC <br /> PHSIEHD 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 /> 9`a <br /> IAME QZt"k Camel S# <br /> [GNATUI ATE 5-23-91 <br /> 'NPANT PRDp)'(dr� CbTpffy TITLE aIVJlaumta. <br /> 89.007(IV)12/90BILFRMI2 <br />