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S1 T, <br /> 'CATION ACKNOWLEDGMENT/REQUEST FOR SERVICED -14 <br /> SAN JOAQUIN`` f - PUBLIC HEALTH SERVICES/ENVIRONMENTAL DIVISION <br /> SITE INFORMATION THER LEAD AGENCY <br /> ITE NAME �� S j - (Q nJ qq l� AGENCY CONTACT <br /> / /1 g�+c� PHONE <br /> MAIN <br /> DRESS 3 j s-rlG i APN 0 16 0 ox <br /> ITr s e�K�D IP gS2D l <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME ULTRAMAR INC ' <br /> ILING ADDRESS 525 WEST THIRD STREET RECEIVED <br /> FEB 2 8 1991 IP 93230 <br /> ;ITY HANFORD <br /> T I 112t Ty lz1 <br /> Pu C HE LTH SERVICES <br /> NTACT NAME RANDALL K. STEPHENSON ENVIRON 9 L H�ATA DNS fiQ�324 <br /> PROPERTY V00@lRATqp <br /> FAMEULTRAMAR INC NONE (209) 583-3324 <br /> 525 WEST THIRD STREETHANFORD TATE CA IP 93230 <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> AME HONE <br /> DRESS <br /> iTT TATE IP <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT <br /> I, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, OF THE PROPERTY LOCATED AT THE A80VE 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 WEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME LIME 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/END HOURLY CHARGES ASSOCIATED WITH THIS ACTIVITY WILL BE BILLED TO THE PARTY IDENTIFIED ABOVE AS THE "RESPONSIBLE PARTY11. <br /> APPLICANT'S NAME, TITLE, SIGNATURE/DATE <br /> AME RA ALL K. STEP ENSON <br /> IGNATURE _ <br /> ITLE ENVIRONMENTAL SPECIALIST II GATE 02/27 91 <br /> PAGE OWE OF TWO <br /> 89-007(IV)12/90BILFRMI2 <br /> J � "� Z 'd 90 : 10 16/ 12/20 /Wl 081 <br />