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' SITE MITIGATION ACKHOWLEDGHENT/REQUEST FOR SERVICES FORM <br /> SAN JOAQUIN COUNTY PUBLIC HEALTN SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> SITE INFORMATION RAPMO <br /> AD AGENCY <br />' CONTACT <br /> ITE NAME <br /> Canteen Corp <br />' <br /> DDRES9 <br /> 1500 Shaw Rd <br />' TTY <br /> Stockton CSI. IP 95205 <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br />' IAMf Canteen Corp <br /> TAILING ADDRESS 1500 Shaw Rd <br /> t <br /> TATF Ca iP <br /> TY Stockton <br />' ONTACT NAME Marc Paschini HONE (209)466-2709 <br /> PROPERTY OWNER/OPERATOR <br /> NONE <br /> LAME <br /> bDRES9 1500 c,hawlid. <br /> TATE IP I <br /> ItY St. =z=j <br /> I <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> HONE <br /> TAME <br /> DbRE55 <br /> TATE IP � <br />' rtY <br />' AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT <br /> !, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, OF THE PROPERTY LOCATED AT THE ABOVE SITE ADDRESS HEREBY <br /> AUTHORIZE INE RELEASE OF ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR ENVIRONMENTAL/SITE SSESSMENT INFORMATION TO <br /> A � <br /> SAN JOAdUIN 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 REPRESEHTATIYf <br />' CLIENT, OR AGENT OF SAME, ACKNOWLEDGE THAT ALL 511E AND/OR PROJECT SPECIFIC <br /> ADDITIONALLY, 1, THE UNDERSIGNED OWNER, OPERATOR, <br /> PHS/EHD HOURLY CHARGES ASSOCIATED WITH THIS ACTIVITY WILL BE BILLED TO THE PARTY IDENTIFIED ABOVE AS THE "RESPONSIBLE PARTY". <br />' APPLICANT'S HANE, TITLE, SIGNATURE/DATE <br />' District Manager So <br /> IAHE Marc Paschina. <br /> ur-- <br /> EGNAIURE G ' <br /> ,y TITLE <br /> OHPANY <br /> 11 107(IY)1119091LFRMIZ <br />