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SITE MITIGATION ACKNOWLEDGMENT/REQUEST FOR SERVICES FORM <br /> SAN JOAQUIN COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> I SITE INFORMATION <br /> 7HER LEAD AGENCY C\1 P WG.G-5 <br /> ITE NAME ry, AGENCY CONTACT <br /> Co,, Co <br /> PHONE q 56 b <br /> DRESS Q 1- roU <br /> 'ITY ✓v'u 60 1 3 2! 626-f C/7- <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME <br /> (LING ADDRESS I__7 a U <br /> IO <br /> TY ��j ! TATE IP S �NTACT NAME /7/q'j/� HONE 0 1 - _ -s-'?'2 <br /> PROPERTY OWNER/OPERATOR <br /> AME ��"rct _ HONE �� L, 5- <br /> DRESS /2 D <br /> ITY � TATE IPS 1 <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> DAME G C-1: Z / i.r nn HONE Qll �3 <br /> DRESS I G 5-6 t[ C S', 160 <br /> fTY le p s 1 TATE IP S 3 <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT <br /> I, 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 HEPLTH DIVISION AS SOON AS IT 1 ILABLE AND AT THE SAME TIME IT IS <br /> PROVIDED TO ME OR MY REPRESENTATIVE. <br /> U L I` °wy <br /> ADDITIONALLY, 1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, 9R AGENT: OF SANE, ACKNOWLEDGE -MT'AkL sml-4PROJECT SPECIFIC <br /> PHS/EHD HOURLY CHARGES ASSOCIATED WITH THIS ACTIVITY WILL BE BILLED T+O.THE •PARTY IDENTIFIED ABOVE AS THE "RESPONSIBLE PARTY". <br /> APPLICANT'S NAME, TITLE, SIGNATURE/DATE <br /> AME �f � /�I L /r� ) [S#1 <br /> IGNATURE �F ATE <br /> OMPANY </ c T�=G y �- TITLE .-* 49 Is-✓/- <br /> PAGE ONE OF TWO <br /> 89-007(IV)12/90BILFRMI2 <br /> EH 29 01 <br /> \ys �' <br />