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MITIGATION 'ACKNOWLEDGMENT/RELIUEST FOSER14. j FORM <br /> _ SAN JOAQtYwwCOUNTY - PUBLIC HEALTH SERVICES/£NVIRONMENTJI✓IIEALTH DIVISION <br /> SITE INFORMATION <br /> DITHER LEAD AGENCY <br /> ETE NAME AGENCY CONTACT <br /> PHONE q <br /> 6DRESS /JrijrS�t.Yt�t 14�e. AFN /3S- o <br /> IP � <br /> BILLING / RESPONSIBLE PARTY INFORMATION 11 <br /> AME J4tJev <br /> AILING ADDRESS. <br /> I �.oS j4 K_ TATE �� IA goo/a <br /> ETY / CoI <br /> ONTACT NAME 14it-• 6(oks, Cx- tr kl HONE C 13� a7Sl- 20 u <br /> II PROPERTY OWNER/OPERATOR <br /> i AME r,- C'k~. JeS a(/ries . f7 HONE )&3 S -a 3CJo <br /> I DDRESS X36/3 Fait- �/vlEy+r /Co�Et� p� <br /> 'ITY .- SCetrlC3 Lt TATE-1CA IP C3 Z6 <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> AME - HONE <br /> DRESS <br /> ITY 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 ABOVE SITE ADDRESS HEREDY <br /> _ I <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 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 PARTY". <br /> APPLICANT'S NAME,. TITLE, SIGNATURE/DATE <br /> AME G"�' - kly L / <br /> [CNATURE � � ATE <br /> Ezzza <br /> kPANT ITITLE <br /> scl <br /> 89.007(TV)12/90BIL'FRM12 <br /> EH 29 01 <br />