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Ra�r?'.a�.... , �ryr��-. ... - .r.�. ra+, ,. z9 .�+�esssasar veax� hz°,t r�a�aes�•cv'nar��°�,a'rwr�re���ar: �c�ti� _ trs: x�arast�r:Exna:s6�',�r�S�'+nts �i;rra.:_,7, b�t'Aransst^.t3�'-Y'- <br /> r <br /> SITE HITIGATICN ACKNOWLEDGMENT/REWEST ;OR SERVICES FORM <br /> SAN JOAOUIN COUNTY • PUBLIC, AEALTH 5-R'lICES/ENVIR0NMENTAL HEALTH DIVISION <br /> SITE INFCRMATICHTHER LEAD AGENCY <br /> AGENCY GCNTACT� <br /> ITE NAME ARCO Service Station No. 2076 <br /> PHONE <br /> -71 <br /> .DDRESS I 800 East Kettleman Lane AaN <br /> Lodi :p 95240 <br /> Irr <br /> SILLiNG / RESPCNSIBLE ?ARTY INFORMATICN <br /> ,AME ARCO Products Company <br /> AILING ADDRESS P.O. Sox 6411 <br /> ITV Artesia CA kip 90702 <br /> � I <br /> ONTACT NAME Chuck Carmel HONE {415} 571-2434 <br /> PROPERTY OWNER/OPERATCR <br /> +AME ARCO Products Com any HONE (415) 571-2434 <br /> DDRESS P.O. Box 6411 <br /> :ITC Artesia FATE CA sP 90742 <br /> CLIENT INFORMATION (IF DIFFERENT FRCti 0',:NER/CPE1qATCR) <br /> TAME Applied GeoSystems, Inc./RESNA Industries NONE {916} 852-6694 <br /> [E:0RESS 3164 Gold Camp Drive, Suite 20O Sacramento rarE CA IP 95670 <br /> AUTHORIZATION TO RELEASEIBILLING ACKNOWLEDGEHENT <br /> 1, THE UNDERSIGNED CURER, CPERATOR, CLIENT, CR AGENT CF SAME, OF THE PROPERTY LCCATED AT THE ABOVE SITE ADDRESS HERESY <br /> AJTHORIZE THE RELEASE CF ANY AI:D ALL ANALYTICAL RESULTS, GECTEZhNICAL DATA AND/CR ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO <br /> SAN JOAOUIN COUNTY PUBLIC IiEALTH SERVICES. £NVIRONNENTAL HEALTH DIVISION AS SCCN AS (T IS AVAILABLE AND AT TI.E SAME TIPiE IT IS <br /> PROVIDED TO ME OR MY REPRESENTATIVE. <br /> ADDITIONALLY, 1, TRE UNDERSIGNED C"ER, CPERATCR, CLSENT, C.2 AGEtiT OF SAME, ACXSCWLZ0CE THAT ALL SITE ,IND/OR PROJECT SPECIFIC <br /> PHSIEHO HOURLY CHARGES ASSOCIATED WITH THIS ACTIVITY WILL BE SItLED TO THE PARTY IDENTIFIED ABOVE AS THE "RESPONSIBLE PARTY". <br /> APPLICANT'S NAME, TITLE, SIGNATURUDATP <br /> LAME Chuck Carmel SSY <br /> ATE 9-13-91 <br /> IGNATLRE <br /> �MPANr ARCO Products Company IITLF <br /> Environmental--Engineer — <br /> 89.007(IV)1219081LFRM12 <br />