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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 <br /> !TE NAMEC 6.(' �ckb- i 1 AGENCY CONTACT <br /> `� cam+ <br /> PHONE <br /> DDRESS /L b✓ Ca✓�.�- oT �!J !/c. (0(/✓Y.� c. f►e( APN # 3 -7- <br /> �es� ��hdsa <br /> ITY <br /> ZIP pS-Za / <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME r d Cklec- e <br /> AILING ADDRESS 3 a S �V �Lr✓�c�Q se <br /> ITY 5fd ck TATE lzIP <br /> ONTACT NAME (F S� �P HONE �2C 1 �% `� �_S �� 1✓� <br /> PROPERTY OWNER/OPERATOR <br /> AME 5� ,�S 60 HONE <br /> DDRESS <br /> ITY isTATE lz <br /> IP <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> DAME 5 �3 � HONE <br /> DDRESS <br /> ITY ISTATE <br /> Ili 5I�1 �y. F E B p 3 1992 <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT SAN JOAQUIN COUNTY <br /> EN ?NlEra �lt�� <br /> I, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, OF THE PROPERTY LOCATED AT THE S ON <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 ! <br /> IGNATURE <br /> DATE <br /> PAGE ONE OF TWO <br /> 89-007(IV)12/90BILFRMI2 <br />