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APN# 17-260-14 <br /> LITE NITIGATI0II AMNOULEDGKEIIT/REWEST FOR SERVICES fORFI <br /> SAN JOAOUIN COU11rY - PLNILIC HEALTH SERVICES/EHVIRONNEWTAL HEALTH OIVISI(W <br /> SITE INFORMATION <br /> THEW LEAs ACEIrcr <br /> [ORM <br /> TE NAME AGENCY CONTACT <br /> M. L Grenz PHONE <br /> AP <br /> I Y <br /> 6540 E, jabant. Ed, <br /> (1V IP <br /> Acawpa- ca- <br /> BILLINQ / RESPCMISISLE PARTY INFORMATION <br /> AHE M.L. Grenz <br /> )LINO ADDRESS 6540 E. Jahant Rd <br /> {TY Acampo, TATE Calif. IIP 1 95220 <br /> OHTACT NAME M.L. Grenz iiONE (209)3697.9094 <br /> PROPERTY OWNER/OPERATOR <br /> AMEM.L,. Grenz HONE (209? 569-9u94 <br /> DRESS 6540 E. Jahant <br /> lif Aram uTE Ca IP (5220 <br /> 18CLIENT INFORNAF)ON (IF DIFFERENT fROI4 OWNER/OPERAIOR) <br /> 106 110N! <br /> DRESS <br /> ITY TATE IP <br /> AUTHORIZATION TO RELEASEISILZING ACKNOULEDGERENT <br /> 1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, OF THE PROPERTY LOCATED AT INF ABOVE SITE ADDRESS HERESY <br /> AUIJIORIZE THE RELEASE OF ANY AILD ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AN0/OR ENVIRONMENTAL/SJTE ASSESSMENT M 0R14A1TON 10 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIROMMEIIJAL HEALIH DIVISION AS SOON AS IT IS AVAILAM AND AT THE SAME LIKE 11 15 <br /> PROVIDED TO ME OR KY REPRESENTATIVE. <br /> ADDITIONALLY, F, INF UNDERSIGNED OWNER, OPERATOR, CLIENT, 'k AGENT OF SAME, ACKNOULEOGE THAT ALL SITE AND/OR PROJECT SPECIFIC <br /> PHS/END HOURLY CIIARGES ASSOCIATED WITH THIS ACTIVITY WILL BE BILLED 10 T11f PARTY IDENTIFIED ABOVE AS TRE "RESPONSIBLE PARIIII. <br /> APPLICANT'S NAME, TITLE, SIGNATUREIDATE G <br /> JANE M.L. Gronz <br /> tGRARTRE - ATE ' ' ^9 <br /> IOMPANVL — <br /> N/A IInE Responsible Parry / Owner <br /> 89 O07(IV)12/908rtfRMI2 <br />