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Post-it"brand <br /> FaxTrans/m�ittal Memo 7672 No.of Pages Today's Dat c� Time <br /> To I'.� c� i h`7klQ /M From M .,y1 yG� I Zi 9 ' 5 C7) <br /> Company e i^"-(. /5 Y'IeQ CJ <br /> Wen rL:V...[,...G..(/ Company L— <br /> Location I'� p� <br /> Location SAI*-T SO� -Cpe[ge <br /> Fax# Telephone# Fax# PUBLI- FB <br /> ENVIRONMEN'Te)!noaZ_ 9P <br /> Comments Original POS OFFICE BOX 2009 <br /> Disposition: ❑D SOCK g11®AL1FC04",9iQQ1 <br /> rnPc��e ar�f 12(X ic 4xy- l�;el5p v 0138. 1-0 (K� <br /> SITIPTIGATION ACKNOWLEDGMENT/REQUEST FOR SERVICOORM <br /> SAN JOAQUIN COUNTY • PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> SITE INFORMATION <br /> THER LEAD AGENCY U RVJQ�B <br /> 31TE NAME 'h" AGENCY CONTACT Pp{{ LOWr-4 <br /> Le r l rlo 'Foods <br /> (� /� .�-�^ PHONE — <br /> DDRESS ,2-q <br /> i O� rnaC A V� I V'L) v- APN # p2 V i._ <br /> ITY �{ (✓. IP �w (� <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME <br /> 1LING ADDRESS <br /> ITY ITATE IP <br /> ONTACT NAME (r� HONE <br /> PROPERTY OWNER/OPERATOR Lp rlio rlJ <br /> AME - e-tL{jo ry)CX. C)OO {l ✓he4` HONE <br /> DDRESS PO SQ)C y� ' aU <br /> ITYPe ioJeV TATE �,� IP <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> AME HONE <br /> DRESS <br /> ITY TATE 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, 1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, ACKNOWLEDGE THAT ALL SITE AND/OR PROJECT SPECIFIC <br /> PNS/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 S# <br /> IGNATUIE ATE <br /> OMPANY TITLE <br /> PAGE ONE OF TWO <br /> 89.007(IV)12/90BILFRMI2 <br /> EH 29 01 <br />