Laserfiche WebLink
R <br /> SITE <br /> SAN JOAQUINCOUNTY�T1PUBLIC NHEALTTHMSERVICES/ENVIRONMENTALEHEALLTH DIVISION L11-2- �� <br /> SITE INFORMATION <br /> Pj�� �/�TC�/�/2/SSS �l/S•� //✓� - THER LEAD AGENCY <br /> ITE NAME AGENCY CONTACT ., <br /> FAPN # <br /> DDRESS �yp 3� /��TTG��4�r/ L,!!�I/� <br /> ITY IP <br /> �NVI ONN4ENTa <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME v✓7 ��/1/Y/P /�E/t/�i�L �/f/�, <br /> I L I NG ADDRESS <br /> ITY TATE � lzIP �J-�91J3 <br /> ONTACT NAME HONE <br /> PROPERTY OWNER/OPERATOR <br /> AME ��/ �iPf /SSS /�� HONE <br /> DRESS <br /> ITY G� � TATE ;i- IP /00/-7 <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> AME 1, <br /> HONE <br /> DRESS <br /> ITY ISTATE1 IP <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 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 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 <br /> AME �A`� I• Y1Iw�` <br /> IGNATURE . <br /> ITLE 5'M(L �06(5�/ � 5 � IY I�F IBJ Z� DATE <br /> PAGE ONE OF TWO <br /> 89-007(IV)12/90BILFRMI2 <br />