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_ y�- - � _ .:roe Ty— � •� � _ <br /> SITE MITIGATION ACKNOWLEDGMENT/REQUEST FOR SERVICES FORM <br /> 517E INFORMATION SAN JOAOUIN COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISICN <br /> THER LEAD AGE Cy ITE NAME ARCO Service Station 2130 AGENCY CONTACT <br /> w <br /> PHONE <br /> DRESS 7906 Borth £1 Dorado Street APN E <br /> ITY Stockton, CA IP 95207 <br /> W ' <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> ,'AME <br /> ICING ADDRESS <br /> -! P.O.P ::)x 5811 <br /> ITY <br /> TATE CA IP 1 94402 <br /> CNTACT NAME Chuck Carmel NONE (415) 571-2434 <br /> y� <br /> PROPERTY OWNER/OPERATOR <br /> A"IE Chuck Carmel N07E 415 <br /> DRESS P.O. Box 5811 <br /> ITY San Mateo TATE CA IP 94402 <br /> CLIENT INFORMATION (IF DIFFER..'-NT FRO14 OWNER/OPERATOR) <br /> AME RESNA Industries Job #30003-4 Hors_ <br /> (916)852-6690 <br /> DRESS 3164 Gold Camp Drive, Suite 200 <br /> ITY Rancho Cordova TATE CA IP 95670 <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT <br /> 1, THE UNDERSIGNED C14HER, OPERATOR, CLIENT, 09 AGENT OF SAME, OF THE PROPERTY LOCATED AT THE ABOVE SITE ADDRESS HEREBY <br /> AUTHORIZE THE RELEASE OF ANY AUG ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR ENVIRONMENTAL/SITE ASSESSMENT INFORMATION To <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISICN AS SOC!I AS IT IS AVAILABLE AND AT THE SAME TWE IT IS <br /> PROVIDED TO ME OR MY REPRESENTATIVE. <br /> ADDITIONALLY, 1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, O1; AGENT OF SAME, ACKNOWLEDGE THAT ALL SITE AND/OR PROJECT SPECIFIC <br /> AHS/END HOURLY CHARGES ASSOCIATED WITH THIS ACTIVITY WILL BE BILLED TO T11E PARTY IDENTIFIED ABOVE AS THE "RESPCNSIBLE PARTY14. <br /> v APPLICANTS NAME, TIT4,' SIGNATURE/DATE <br /> IAME Chuck Carmel Sr 545-138355 <br /> IGNATURE <br /> ATE 2/10/92 <br /> :QMPANY _ARCO Products compary Environmental Engineer <br /> ITLE <br /> S9.00T(IV)i2/g08ILFRM12 <br />