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S1 TIGATION ACKNOWLEDGMENT/REQUEST FOR SERVI;�ORM <br /> SAN JOAQUIN COUNTY • PUBLIC HEALTH SERVICES/ENVIRONMENTAL LTH DIVISION <br /> SITE INFORMATION <br /> THER LEAD AGENCY <br /> • ITE NAME AGENCY CONTACT Mary Maeys <br /> California Natural Products <br /> PHONE 209/858-2525 <br /> DRESS 1250 Lathrop Road East APN k <br /> ITY Lathrop, CA IP 95330 <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME AU eas Corporation <br /> (LING ADDRESS 799 Main Street, Suite A <br /> TY Half Moon Bay, CA 3TATE CA IP 94019 <br /> ONTACT NAME HONE <br /> PROPERTY OWNER/OPERATOR <br /> AME California Natural Products 1PHONE 1 209/ 858-2525 <br /> %DDRESS 1250 Lathrop Road East <br /> ITYLathrop, TATE I CA �zipj 95330 <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> • AME HONE <br /> OORESS rATML-N ' <br /> ITY TATE IT+` <br /> SAN JOAQUIN COUNTY <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <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/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 /> aME Rosanna Garrison S# 370-62-1962 <br /> IGNATURE ATE <br /> • OMPANYAU eas Cor ratMln ITLE President <br /> 89.007(IV)12/9OBILFRMI2 <br /> EH 29 01 <br />