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J MITIGATION ACKNOWLEDGMENT/RECIUEST FOR SERVJ FORMS <br /> SAN JOACiw_LOUNJTY PUBLIC HEALTH SERVICES/EHVIROHMENTS. EALTH DIVISION <br /> SITE INFORMATION <br /> THER LEAD AGENCY <br /> 1TE NAME ' AGENCY CONTACT <br /> PHONE <br /> DRESS rJ 1� Pers f 14 APN # 13,,5- /;ZO-01 <br /> ITY (FTOG/Z_7(a t / - 014 IP <br /> BILLING /-RESPONSIBLE PARTY INFORMATION <br /> AME ��AJe7J F CrAlAl_f0'd. (71 4Gc� <br /> (LING ADDRESS X676 GJ;Ishf/e <br /> 1TY COs hy PICS 3TATE 04 �lp I6 010 <br /> ONTACT NAME_ 'I r• cloy/-L Caj. 4,f HONE <br /> PROPERTY OWNER/OPERATOR <br /> AME Mr, 4r?cA, r ✓_ S^o,// HONE (269)Al�t8 <br /> DORESS - COIk CJ;4- , Cr•SrCle_ p <br /> - I TY - 'S TATE [�f} I P 1 7 <br /> CL?ENT .INFORMATION (IF DIFFERENT-fROM OWNER/OPERATOR) <br /> AME HONE <br /> ODRESS - <br /> ITY - - TATE EP <br /> . - n <br /> AUTHQQjZAT;ION TO RELEASE/BILL-ING ACKNOWLEDGEMENT <br /> i, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, OF THE PROPERTY LOCATED AT THE ABOVE SITE ADDRESS HEREBY_ <br /> i <br /> AUTHORIZE .1-HE .RELEASE OF ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO <br /> SAN JOAQUINJ COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS <br /> PROVIDED TO ME OR MY REPRESENTATIVE. <br /> ADDITIONALLY, 1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME., ACKNOWLEDGE THAT ALL SITE AND/OR PROJECT SPECIFIC <br /> P41S/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 LILL)60 rp 7-3763 <br /> SIGNATURE- �,. ATE <br /> OMPANY. E ITLE <br /> 89-G07(IV)12/409ILFRMI2 <br /> EM 29 01 <br />