Laserfiche WebLink
SIT"-4W4TIox'ACKNOGLEDGMENT/REGUEST FOR SERVICE <br /> :i SAN JOAQU14I,,NTY - PUPLIC HEALTH SERVICES/ENVIRONMENTAL+ DIVISION <br /> SITE INFORMATICN HER L AGENCY <br /> 1 AGENCY CONTACT <br /> gNAME ;�EAST;N; <br /> N 9=1918 <br /> PHONE <br /> APN # <br /> lP <br /> 95204 <br /> BILLING 0 RESPONSIBLE PARTY INFORMATION <br /> AME EA ENGINEERING, SCIENCE- AND TECHNOLOGY, INC. <br /> ,I 6 <br /> iLING ADDRESS 41 LAFAYETTE CIRCLE <br /> ITY is LAFAYETTE, CALIFORNIA ii TATE CA IP 9 _ <br /> I HONE 415) 283-7077 <br /> NTACT NAME' JAN STEPEK <br /> PROPERTY OWNER/OPERATOR j <br /> HONE <br /> ffEC�IHEVRON USA, INC. — <br /> P.O. BOX 5004 <br /> SAN RAMON TATEIA <br /> IP 45$3-0804 <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> HONE <br /> ME <br /> DRESS <br /> ITY - TATE I IF <br /> �y II <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT. <br /> 1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, OF THE PROPERTY LOCATED AT THE ABOVE SITE ADDRESS HEREBY <br /> AUTHORIZE THE RELEASE OF ANY AND ALL ANALYTICAL, RESULTS, GEOTECHNICAL DATA ANO/OR ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO <br /> A <br /> SAN JOAQUIN'COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT Is <br /> PROVIDED TO M£-OR MY REPRESENTATIVE. -' �- <br /> ADDITIONALLY, 1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, ACKNOWLEDGE THAT ALL SITE ANO/OR PROJECT SPECIFIC <br /> i <br /> �• PHS/EHO HOURLY CHARGES ASSOCIATED WITH THIS ACTIVITY WILL DE BILLED TO THE PARTY IDENTIFIED ABOVE AS THE "RESPONSIBLE PARTY". <br /> ii <br /> APPLICANT'S NAME, TITLE, SIGNATURE/DATE <br /> AME JAN STEPEK, SENIOR HYDROOGEO�LOGIST/ EA ENGINEERING, INC. <br /> [GNATURE <br /> ITtE ENIOR HYDROGEOL22 OGIST DAT <br /> 'SE April. 19 1 . <br /> .1 <br />