Laserfiche WebLink
SITE M \TION ACKNOWLEDGMENT/REQUEST FOR SERVICES <br /> SAN JOAQUIN COt*ai - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA..R DIVISION <br /> SITE INFORMATION <br /> THER LEAD AGENCY <br /> ITE NAME AGENCY CONTACT <br /> PHONE <br /> Iftow <br /> G rc n} (-e1^r 12d- }It-cY` i2 d 2 fiHe 20 S ��-eQ.✓��/ <br /> DRESS APH # <br /> ITY _ 1P <br /> I j 2c <br /> BILLING / RESPONSIBLE PARTY INFORMATION V 2 nit 4% <br /> AME ,"���1•en� �e.��lo �n'�" �ir2c zr er F-WRONMENTAL HEALTH <br /> IL1NG ADDRESS -Z3p0 <br /> ITY �2�by Crit�� TATElzip I qiT LA <br /> ONTACT NAME /'1 r. Tf�r��S �''LP�2 HONE y 15 --7,5 -7 3-nv <br /> PROPERTY OWNER/OPERATOR, <br /> AME 17t G(t/�(S �f✓e�t) fry �'2� ('� /'S HONE Lf I -25G --730 <br /> %DDRESS Z 3� D2n✓ �� e , <br /> [TY Lja Ile\ �-- �('te K- ISTATE I CA- IP I q y(;-y 5- <br /> CLIENT INFORMATION (1F DIFFERENT FROM OWNER/OPERATOR) <br /> WE IIONE <br /> DDRESS <br /> ITY TATE I IP <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT <br /> 1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, OF THE ROPER' LOCATED S HEREBY <br /> AUTHORIZE THE RELEASE OF ANY AND ALL ANALYTICAL RESULTS, GEOTECHNI AL DATA AND/OR EIIVIRONMENTAL/SITE ASSESSMENT INFORMATION TO <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH [VISION AS SOON AS IT IS AVAILABLE 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 AND/OR PROJECT SPECIFIC <br /> PHS/EHD 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 /> DAME A-. SMeaK psly <br /> IGNATURE C( TATE <br /> S-13-Q <br /> MPANY p1C�`C_ �c 0 G• TITLE <br /> O <br /> 89-007(IV)12/908[LFRM12 l <br />