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SITE M'TtGATION ACXN0WLZDGMCNT/RS0UEST FOR SERVICES -`QW <br /> SITE INFORMATION SAN JdACUIN C - MIC HEALTH SERVICES/ENVIRONMENTAL WV DIVISION <br /> HER LOAD AGENCY WO r. 7R <br /> ITE NAME I 1 AGENCY CONTACT 1��1 S or E_r\o <br /> PHONE <br /> �V <br /> ITT ��"4 C..�-•-�d f�, �Q.,-l 1 �d r �1 ( C�, ZIP <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> iLING ADDRESS <br /> ITY. Y" STATE <br /> TACT NAME 2 1.G' . 271 —S 8 S7 <br /> PROPERTY OWNER/OPERATOR <br /> E <br /> 01 1, Vv-.Q 0.y-, MONS <br /> ORES5 LJIZZO E <br /> ITT C, G V L�O_V\.GC. TATE O (� 1 P <br /> CLIENT INFORMATION CIF DIFFERENT FRQ4 OWNER/OPERATOR) <br /> E HONE <br /> DRESS <br /> tTY TATE IF <br /> FEB 0 5 1993 <br /> AUTHORIZATION TO RELEASE/BILLING ACXNOWLEDGEMENT <br /> I, THE UNDERSIGNED OWNER, OPERATOR, � tlCll! 1�, OF THE PROPERTY LOCATED AT THE ABOVE SITE ADDRESS HERESY <br /> ��T?1�117�/$ERVICES <br /> AUTHORIZE THE RELEASE OF ANY AND.ALL ANALYTICAL-RESULTS, OEOTECHkICAL DATA ANO/OR ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO <br /> SAN JOAQUIN COUNTY PUDLIC NEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION AS SON AS IT IS AVAILABLE AND AT THE SAME TIME IT is <br /> PROVIDED TO ME OR MY REPRESENTATIA. <br /> ADDITIONALLY, 1, THE UNDERSIGNED.OWNER, OPERATOR,.CLIENT„OR..AtENT. OF SAME, ACXRCWLEDCE THAT ALL SITE AHD/OR PROJECT SPECIFIC <br /> PHS/END HOURLY CHARGES ASSOCIATED WITH THIS ACTIVITY.VILL.BE.AILLED.TO T11E PARTY IDEXTIFIED ABOVE AS THE "RESPONSIBLE PARTT". <br /> APPLICANT'S NAME, TITLE, SIGNATURE/DATE <br /> 4AME IChard C, Lot uba. cr S zB��yZ-32s � <br /> 1GNATURE y COL <br /> ATE rj IS19F <br /> fL 7 <br /> PANT l,1 1 Co. IT1 T LE f Tv ckrA P_ O r I .I• <br /> s9•aort lv)12/90a1 LFRnta <br />