Laserfiche WebLink
SIT�IGATION ACKNOWLEDGMENT/REQUEST FOR SERVIC RM <br /> SAN JOAOUIN C NTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL*LTH DIVISION <br /> SITE INFORMATION <br /> DINER LEAD AGENCY <br /> FITNAME AGENCY CONTACT <br /> Stonebridge Industrial Park, Lot 8 <br /> PHONE 209 68- <br /> Lk <br /> antline Road APH k P r i 237-020-1 <br /> California Fp <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME Mark II Engineering Contractors <br /> AILING ADDRESS c/o Raney Geotechnical, 1376 Industrial Boulevard <br /> ITY West Sacramento STATE CA IP 1 95691 <br /> 'ONTACT NAME HONE <br /> PROPERTY OWNER/OPERATOR <br /> AME Mark III HONE 381-8080 <br /> %DDRESS 1501 Florin-Perkins Road <br /> ITY Sacramento TATE CA IP 95826 <br /> 'CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> LAME HONE <br /> DDRESS <br /> (TY IS TATE IP <br /> ,7,qto <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT <br /> i, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR eGEIIT OFSAM, 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 JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILA3LE AND AT THE SAME TIME IT IS <br /> PROVIDED TO ME OR MY REPRESENTATIVE. - <br /> ADDITIONALLY, 1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, ACKNOWLEDGE THAT ALL SITE ANO/OR PROJECT SPECIFIC <br /> PHS/END 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 Mike Gereghty IS SN 561-86-7639 <br /> SIGNATURE <br /> ATE 1/2/92 <br /> OMPANY Ra y Geotechnical ITLE Environme <br /> JAN 0 3 1992 <br /> 89.007(IV)12/90BILFRMI2 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br />