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SIrE INFORMATION <br /> !r NSF ASIT E Mfr <br /> [�SAA TBIC lONsEIRfG1 INccvmrypLNi �F0, <br /> ".ME�v[Cg"N1N <br /> TAt )i <br /> A o7H <br /> EI DoradSo H DIVISION �# <br /> 1: Housing HER Ll ao F,. <br /> DRESS AdENCY <br /> 170 AGENCY �rACT Cit o1 Stockton, <br /> S. <br /> El � ado Street PHONE Wes Kum <br /> 994-8822 tT` <br /> fry APN # 167- <br /> Stockton CA 95206 033_18 <br /> BILLING / RESPONSIBLE PARTY INF [P <br /> ArlON <br /> ANE <br /> [LING ADDRESS <br /> 7808 Kell y Drivei <br /> Suite E <br /> ITY �J <br /> Stockton <br /> TATE CA IP 95207 <br /> NTACT HANE W. Ter-ren e Hull ; <br /> PROPERTY OWNER/OPERATOR HONE 474-2011 <br /> ME Cit of Stockt n � <br /> HONE 944_8$22 <br /> ORIeBS 305 N. El Dora o <br /> ITY Stockton <br /> TATE rP 95202 'k' <br /> CLlEHI INFORMATION (!F DIFFERENT FROM OWNER/OPERATOR) <br /> AME CAREfilled Home Inc. HONE <br /> 474-2Q11 <br /> DRESS 7808 Kelley Dri e, Suite E <br /> :fly Stockton ISTATV2 CA IP 95207 <br /> AUTHORIZATION TO RELEASE/BILLIN ACKNOWLEDGEMENT <br /> 1, THE UNDERSIGNED OWNER, OPER TOR, CLIENT, OR AGENT OF SAME, OF THE PROPERTY LOCATED AT THE ASOVE SITE ADDRESS HEREBY <br /> AUTHORIZE THE RELEASE OF ANY A 0 ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR ENVIRONMENTAL/SITE ASSESS JI NT INFORMATION TO <br /> SAN JOAQUIN COUNTY PUBLIC HEAL H SERVICES. ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT IIIHESAME TIME IT 'IS <br /> PROVIDED YO HE OR MY REPRESENT TIVE. <br /> 1 <br /> ADDITIONALLY, 1, THE UNDERSIGN D OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, ACKNOWLEDGE THAT ALL S17E AND/00. PROJECT SPECIFIC <br />•- PHS/EH0 HOURLY CHARGES ASSOCIA ED WITH THIS ACTIVITY WILL BE BILLED TO THE PARTY IDENTIFIED ABOVE AS THE "RESPONSIBLE PARTY".,� <br /> 4 <br /> t. .i <br /> APPLICANT'S NAME, TITLE, SIGNA7 E/DATE <br /> AME CAREfilled Hdnes, Inc. <br /> tGNATURE <br /> 1 TLE Chairman T DATE August 6, 1992 <br /> PAGE ONETWO <br /> AUG 0 7 1992, j... <br /> 4 8g•007tTY)12/�Os1LPRM12 ` � <br /> ENVIRONMENTALhtL "! i�: � <br /> l RMIT/-SERVICES <br />