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' STATE NT ACKNOWLEDGMENT/REQUEST FOR SERVICES FORM <br />s t SAN JOAQUIN CITY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br />SITE INFORMATION <br />THER LEAD AGENCY <br />ITE NAME L ` µ . t AGENCY CONTACT <br />I ITY I ` C <br />BILLING / RESPONSIBLE PARTY INFORMATION <br />i <br />PERMIT/SERVICES <br />AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT <br />I, THE UNDERSIGNED 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 IS <br />PROVIDED TO ME OR MY REPRESENTATIVE. <br />ADDITIONALLY, I, THE UNDERSIGNED 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 C <br />AME t.. y 6a.L. ® 0 L t& { VN I IsmOrt — — <br />IGNATURE J&-PJLATE J <br />89-007(IV)12/90BILFRMI2 <br />EH 23 029 <br />., <br />V � <br />" r <br />NAME <br />i <br />PERMIT/SERVICES <br />AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT <br />I, THE UNDERSIGNED 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 IS <br />PROVIDED TO ME OR MY REPRESENTATIVE. <br />ADDITIONALLY, I, THE UNDERSIGNED 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 C <br />AME t.. y 6a.L. ® 0 L t& { VN I IsmOrt — — <br />IGNATURE J&-PJLATE J <br />89-007(IV)12/90BILFRMI2 <br />EH 23 029 <br />