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SITEOIGATION ACKNOWLEDGMENT/REQUEST FOR SERVICEIPORM <br /> SAN JOAQUIN COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> SITE INFORMATION THER LEAD AGENCY <br /> 1ry�n,rrl� AGENCY CONTACT <br /> ITE NAME ` v�,v � PHONE <br /> Ye e S j 5 1992 <br /> y/�f OCT N 11 <br /> DDRESS �L/ C/UO YCG/� �OR J()PQUIN Cq3 <br /> {t } ENV RONMENTAL HEALZN V J <br /> ITY Ip -4 �Gfj C /f- �t7 33('^ <br /> BILLING / RESPONSIBLE PARTY INFORMATION 1 / <br /> AME S L .. e S <br /> ILING ADDRESS 8 iw ,S Lee, <br /> ITY � a Q. Cir CLQ HONE / <br /> ONTACT NAME J Y e gL �"► / 2— <br /> PROPERTY OWNER/OPERATOR //� HONE S Z 3 Z <br /> AME 5 yrt L ate. "S SEl el .F.-- G c� <br /> DDRESS � p ,f ¢G�L <br /> TATE IF L <br /> ITY 0 G C <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> HONE <br /> TAME /L,/ecJ <br /> DRESS <br /> TATE IP <br /> ITY <br /> AUTHORIZATION i0 RELEASE/BILLING ACKNOWLEDGEMENT -J`I� `,'C <br /> AA 11�55iYV*'`.� OVE SITE ADDRESS HEREBY1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, OF THE PROPERTY VC G`` \04 <br /> AUTHORIZE THE RELEASE OF ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/A NY�RIHIRAQL IT�,�ASSESSMENT INFORMATION TO <br /> AS SOON THE SAME TIME IT IS <br /> 401J1`I ,..rtfj <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION <br /> LN� l�� A � <br /> PROVIDED TO ME OR MY REPRESENTATIVE. PolaO0%0�L <br /> ADDITIONALLY, 1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, EDGE.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 /> 1 Sk <br /> AME \1 Ii e <br /> ATE <br /> IGNATURE Jl <br /> TITLE <br /> OMPANY J /veck2 /f, l� , <br /> 89-007(IV)12/9081LFRM12 PAGE ORE OF TWO� <br /> EH 29 01 if 2 <br /> s _ <br />