Laserfiche WebLink
sill ,LIGATION ACKNOWLEDGMENT/REQUEST FOR SERVIL. M <br /> SITE INFORMATION % <br /> SAN JOAQUIN � TY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEZ�TH DIVISION <br /> OTHER LEAD AGENCY Pa Y <br /> 31TE NAME THRIFTY OIL CO. SS#172 AGENCY CONTACT EC <br /> PHONEAPR16 rt <br /> DDRESS 7647 Pacific Avenue s APH # pUB U11V OU 1NTy <br /> ITY Stockton i HI 'LTH <br /> ENVIR � � Ne _ P <br /> 95207 <br /> BILLING / RESPONSIBLE PARTY INFORMATION 2 Z 7 <br /> AME THRIFTY OIL CO. <br /> AILING ADDRESS 10,000 Lakewood Boulevard <br /> Iry Downey TATE CAIP 90240 <br /> :ONTACT NAME Peter D'Amico HONE ( 3') 923-9876 <br /> PROPERTY OWNER/OPERATOR <br /> AME THRIFTY OIL CO. IP111E <br /> DDRESS 10,000 Lakewood Blvd. <br /> ITY Downey TATE IP I 9024C) <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> LAME 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, ENVIRONMEIITAL HEALTH DIVISIC`! AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME 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/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 Peter D'Amico IS S# <br /> IGNATU E ` ATE <br /> OMPANYjr TITLE <br /> f IFTY OIL CO.89-007(IV)12/90BILFRMI2 <br />