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SITE DATION ACKNDWLEDGMENT/REQUEST FOR SERVICES m o%9- q <br /> SAN JOAQUIN COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEt DIVIS 1 1 ' �� r <br /> SITE INFORMATION <br /> SL1.f1 TN TSA,- EhlCY �Y <br /> ITE NAME f,4�nit�� AGENCY CONTACT c � R <br /> 1-1 ( PHONE 09 q <br /> DRESS I f 11� RS.F;CdN OF' J <br /> 150 t�05� f�A �JW E �lasra; � Ro fz APN # �. ,PUSS C c%jA\lt� <br /> IrY jZ -��� � '�1 IP Lr 1L, t roAf <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME �a E- 2 <br /> ILING ADDRESS 5 SOJ�QWI COUMT CAP/T -L, �'eVTEC CiDuNmq }�0(�rj goDpM 6:7B <br /> ITY 5`i`�j C�('fn� TATECly, IP 9SZ0Z <br /> E b L? o <br /> NTACT NAME I-1 S`I'E(IE E T�I HONE <br /> PROPERTY OWNER/OPERATOR <br /> AME M1Z. 5 r�VE E fEtZ� HONE <br /> DRESS j !j 6 HaS�rTJ}pL CSA N t� <br /> ITY R�N C, Mm TATE C4� 1P <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> AME BILLINb A"rod5lb(.r- HONE <br /> DRESS <br /> ITY TATE IP <br /> �C� SCS <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT <br /> I, 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 AND/OR ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO <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 ME OR MY REPRESENTATIVE. <br /> ADDITIONALLY, I, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, ACKNOWLEDGE THAT ALL SITE AHD/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 /> s <br /> f AME <br /> IGNATURE <br /> ITLE C� / lV rfG DATE <br /> t <br /> 1 <br /> PAGE ONE OF TWO <br /> E-O07( 12/9081LFRMI2 <br />