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I w <br /> SI'-,�'ITIGATION ACKNOWLEDGMENT/REQUESTJGFOR SERvIC' <br /> Sq - -'JR*�1�' <br /> SAN UI NTY <br /> 'SITE IkFCR!!ATipN PUBLIC HEALTH SERVICES/ENVIRONMENTAL '(H DTVI <br /> TH �EAD AGENCY <br /> W153' AGENCY C0NTACT <br /> PHONE <br /> ��t>�'/ <br /> IP <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME L,.�l'1/ <br /> !LING ADDRESS <br /> y � <br /> t TY �f�� <br /> TATE <br /> ONTACT NAME /S'1.��P/l /, /��/GCE/Z HONE C-7- <br /> PROPERTY OWNER/OPERATOR <br /> AME HONE <br /> DRESS <br /> ITTov.�� �S TATE I P <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> AME <br /> HONE <br /> DRESS <br /> tTY TATE IP <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT <br /> ENPARONMENTALHEAD <br /> 1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, OF THE PROPERTY ffL9W/kfRWGffiVE (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 OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, ACKNOWLEDGE THAT ALL SITE AND/CR PROJECT SPECiFiC <br /> AHS/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 <br /> IGNATURE �. <br /> IiLE •(�p� {�[��s(`ar { QJ _� IV fTyf�IC-� DATE <br /> PAGE ONE OF TWO <br /> 89-007(IV)12/90BILFRM12 <br />