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SITE MITIGATION ACKNOWLEDGMENT/REQUEST FOR SERVICES FORM <br /> SAN JOAQUIN COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> SITE INFORMATION <br /> THER LEAD AGENCY CRWQCB-Central Reg on <br /> [TE NAME U.S. Defense Distribution Region West (DDRW) AGENCY CONTACT Camilla Williams <br /> Tracy <br /> PHONE (916) 361-5670 <br /> DDRESS APN # <br /> 25600 Chrisman Road <br /> ITYIP <br /> Tracy, California 95376-5000 <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME Woodward-Clyde Consultants <br /> 11AILING ADDRESS 500 12th Street, Suite 100 <br /> ITY Oakland STATE CA IzIp <br /> 94607-4014 <br /> ONTACT NAME R. Siegel, Project Manager DHONE (510) 874-3093 <br /> PROPERTY OWNER/OPERATOR <br /> AME U.S. Defense Depot-Tracy 1PHONE 1 (209) 832-9532 <br /> DDRESS 25600 Chrisman Road <br /> ITY Tracy TATE I CA IP 95376-5000 <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> DAME HONE <br /> DRESS 'PA Y ME E N f <br /> ITY <br /> SAN JOAQUIN COUNTY <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT PLI^LIC HEALIH SEPVIC S <br /> ENVIRONMENTAL HEALI H DIVISION <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 AND/OR ENVIRONMENTAL/SITE ASSESSMENT 114FORMATIOII 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, 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 / / //C� <br /> AME Va `��5 ��/ //��� S# 3 �v�7 /1 <br /> SIGNATURE MATE12 <br /> oMPANY Woodward-Clyde Consultants i1TLE �5 �S h;t aCt <br /> PAGE ONE OF TWO _ <br /> EH 29 0C <br /> �(� J b <br /> IV)12/9061LFRM12 <br /> E H 29 O 1 G� <br />