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SIT TIGATION ACKNOWLEDGMENT/REQUEST FOR SERVICE ORM / <br /> SAN JOAOUIN�TY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL�TH DIVISION <br /> -SITE INFORMATION 1-01 <br /> LEAD NIL ID <br /> tTE NAME Glenbriar Estates AGENCY CONTACT <br /> PHONE <br /> `+ DRESS 27383 South MacArthur Road APN <br /> ITT Tracy, CA IP /a <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> CCN �`��, ✓ <br /> AME American Environmental Management Corporation V/ <br /> ILiNC ADDRESS 9719 Lincoln Village Drive, Suite 501 �T/ qty <br /> ITY Sacramento FTATTSCA reIP 95827 <br /> ONTACT NAME <br /> Mark Reisig HONE 1 (916) 364-8872 <br /> PROPERTY OWNER/OPERATOR <br /> AME Homestead Land Development HONE <br /> DRESS <br /> P.O. BOX 960 <br /> ITY Millbrae TATE CA IP 94030 <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> TAME Same As Property Owner HONE <br /> DDRESS <br /> ITY TATE IP <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT qP <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 /> S�N JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS <br /> PRIVIDED TO ME OR MY REPRESENTATIVE. <br /> AOCITIONALLY, 1, 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 /> LAME Yj E S F. 2[//I74 <br /> IGIIATURE <br /> ITL g cc�/r/�� L /"��/Y�-��/Z DATE �UN t S g <br /> B9-007( IV)12/90BILFRMI2 <br /> 1 <br />