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SIT ► GATION ACKNOWLEDGMENT/REQUEST FOR SERVIC f RM <br /> SAN JOAQUI - PUBLIC HEALTH SERVICES/ENVIRONMENTA DIVISION <br /> SITE INFORMATION / <br /> THEk LEAD AGENCY c- +_c: <br /> ITE NAME y AGENCY CONTACT ��o/ <br /> +�L/S` IJP Cte�✓. e PHONE <br /> DRESS LlU , / ��. APN # <br /> ITT r IP <br /> d C�� <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME <br /> (LING ADDRESS ��Z S '� G✓� <br /> I TY TATE C�1/ I P <br /> CNTACT NAME 9OaV "'/ STl^�J HONE G �j 3 �J /,7 .5r 3 <br /> PROPERTY OWNER/OPERATOR <br /> / y44 ■ <br /> AME dJHONE <br /> DRESS <br /> ITY TATE IP <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> AME < 4S It HONE <br /> DRESS <br /> ITY TATE IP <br /> AUTHORIZATION TO RELEASE <br /> THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, OF THE PROPERTY LOCATED AT THE ABOVE SITE ADDRESS HEREBY <br /> UTHORIZE THE RELEASE OF ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME ITIS <br /> ROVIDED TO ME OR MY REPRESENTATIVE. <br /> DITIONALLY, 1, THE U G D-: , , CLIENT, OR AGENT OF SAME, ACKNOWLEDGE THAT ALL SITE AND/OR PROJECT SPECIFIC <br /> HS/EHD HOURLY CHARGES SSOCIEATED l THIS A' IVITY WILL BE BILLED TO THE PARTY IDENTIFIED ABOVE AS THE "RESPONSIBLE PARTY". <br /> APPLICANT'S NAME, TITLE, SIGNATURE/DATE <br /> AME <br /> IGNATURE <br /> ITLE /�� % I ud/O l� C �/T/ ��� DATE Z // <br /> PAGE ONE OF TWO <br /> 89-007(IV)12/90BILFRMI2 <br />