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5' MITIGATION ACKNOWLEDGMENT/REQUEST FOR SERV,' ',FORM <br /> SAN JOAQQWoOUNTY PUBLIC HEALTH SERVICES/ENVIIONMENT LTH DIVISION <br /> SITE INFORMATION THER LEAD AGENCY <br /> ITE NAME HUSKY CRANE AGENCY CONTACT <br /> PHONES' <br /> DRESS 2373 MARIPOSA ROAD APN M pp >o <br /> I <br /> r ITr $TOCKTON; CALIFORNIA %. a IP 95205 <br /> 102- 34P I <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AMB HUSKY CRANE ) DEC 1 3 1991 <br /> (LING ADDRESS 2373 MARIPOSA ROAD ENVIRONMENTAL HEALTH <br /> -'I TY STOCKTON ) TATE CA IP 95205 <br /> oNTACT NAME HIM BAILEY, "_Secretary jf ONE (209) 464 7635 <br /> PROPERTY OWNER/OPERATOR <br /> AME HUSKY ANEHONE 9 6 <br /> 35 <br /> DD RE ss 2 MARIPOSA ROAD <br /> ITY STOCKTON TATE CA IP 95205 <br /> CLIENT INFORMATION (IF DIFFERENT FROM CWNER/OPERATOR) <br /> AME HONE <br /> OORESS <br /> ITr IP <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT <br /> I, 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 1S <br /> li <br /> PROVIDED i0 '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 /> i <br /> DHS/END HOURLY CHARGES ASSOCIATED WITH THIS ACTIVITY WILL BE BILLED TO THE PARTY IDENTIFIED ABOVE AS THE "RESPONSIBLE PARTY". <br /> I <br /> i <br /> APPLICANT'S NAME, TITLE, SIGNATURE/DATE <br /> AME l SN <br /> it l2� 13 �R( <br /> IGNA TORE I ATE <br /> OMPANY Husky Crane, Inc ITLE Secretary <br /> I <br /> 89-007(IV)12/908ILFRM12 <br /> • EN 29 01 <br />