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05it3i91 13 33 X 7145570353 WarkrntinWrai9ht t5 <br /> qj- 17 <br /> SITE MITIGATION ACKHOWLEOCMENT/REQUEST FOR SERVICES FOR!` , <br /> S10N <br /> SAN ,JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENYIROWENTAL HEALTH O1VI <br /> 1E lNFCRMAitON <br /> THER LEAD AGENCY QF', <br /> Fo ado Pro,," AGENCY CONTACT 99� <br /> ITE HAKE PHONE <br /> ,2 d a. fi e 20 <br /> Gt2n� APH if <br /> ORE <br /> 13 <br /> 1 3170 crrz-+ �,�c 2� . D <br /> IP <br /> 'ITT \ <br /> Tti 2c , <br /> BJLLING / RESPONSIBLE PARTY INfORMATION <br /> AME ,`✓i�v�C� lit-�f�o rn+ '�rd c d r�.�r <br /> (LING ADORESS Z3oo Dar ,.,!hc a( . <br /> J <br /> IT I,..JZf At) TATE Gam' lP q Lf S-9 <br /> L-ONTACT NAME r. fir} s /nt-cfa I HCNE 141 T 'Z,_S - 7 300 <br /> PROPERTY OWNER/OPERAICR <br /> AME 0tv�6-rid Dejclo-meAl, i 2LPd rAncrS HONE KI T--25Z. <br /> ..DRESS ` Z 3 Da•1�,ti( c (3 t , <br /> ITT (,.)Z1"a CCtt K' TATE IP <br /> ( tEdf INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> lA,+E HONE <br /> DRESS <br /> 11Y TATE IP <br /> AUTHORIZATION TO RELEASE/81LU NG ACXNOW'LEEOGENENT <br /> 1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AG911T 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 EIIV(RO1lMaNTAL/SITE ASSESSMENT INFORMATION TO <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMEIITAL HEALTH DIVISION AS SCON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS <br /> PROVIOEO TO ME OR MY REPRESENTATIVE. <br /> AOOITIOHALLT, I, THE UNDERSIGNED OWNER, OPERATOR, CLIVJT,:OR AGENT Of SAME, ACXNOWLEOGE THAT ALL SITC• AND/OR PROJECT SPICI►IC <br /> PMS/ENO HOURLY CHARGES ASSOCIATED WITH THIS ACTIVITY WILL BE BILLED TO THE PARTY IDENTIFIED ABOVE AS THE "RESPONSIBLE PARTY". <br /> APPLICANT'S NAME, TITLE, SIGNATURE/OATE <br /> F <br /> E MCT SK <br /> r' IMMURE C( ATE 5- 1.7—q( <br /> CMPANT ^b1C�C ^t'c 0 C TITLE <br /> 89.007(JV)12/9081LFRM12 <br />