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SITE 'GATION ACKNOWLEDGMENT/REQUEST FOR SERVICE' loll <br /> SAN JCAQUIN.,►i OCY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL 44TH DIV q)-6q47 <br /> SITE INFORMATION <br /> T AGENCY <br /> ITE NAME ? / AGENCY CONTACT <br /> •�'-7 ,/� / j�/ / / PHONE <br /> DRESS APN # �� �.- jd ZI GP <br /> 2- <br /> !TY iP <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME J <br /> AILING ADDRESS C7_ /jckb r � <br /> �, [i/U72 <br /> iTY v' tr ' T.k' IP 7�? <br /> rv� <br /> 'ONTACT NAME �! Ad" 713 4,56 - � d <br /> PROPERTY OWNER/OPERATOR <br /> AME � ��� HONE <br /> DRESS <br /> ITY TATE IP <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> AME lei c as, .09c,,e HONE <br /> DRESS <br /> tTY TATE IZ IP <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT <br /> t, 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 /> LAME OtJ c3 r IS4!1 <br /> IGNATUREi ATE o <br /> OMPANY ) vv. TITLE - � <br /> A11 G 151991 <br /> 89-007(tV}12/90BILFRMI2 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT!SERVICES <br />