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(property owner name} <br /> owner mailing address) f <br /> r <br /> (city, state, ZIP) <br /> fl <br /> RE: (site address) <br /> J <br /> I(We) declare that the assessment activity being per ormed at the <br /> above referenced site is being conducted with my(our) riawledge and <br /> approval. Furthermore, I (wa) acknowledge that payme t of FHS-EHD <br /> charges will become my(our) responsibility in th ;event said <br /> charges are not paid by the client and/or operator dentified on <br /> the attached ,site Mitigation Acknowledgement/Reques f'or services <br /> Form. <br /> (signature and title) j (phone u' er) <br /> - ll9L <br /> (date) <br /> I <br /> LC\HILACKN.FRM <br /> j <br /> l <br />