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SI TIGATIDN ACKNOWLEDGMENT/REQUEST FOR SERVI 'ORM <br /> SAN JOAQUIN ..,JNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL ..cALTH DIVISION <br /> SITE INFORMATION <br /> THER LEAD AGENCY 4Ile y R&,J re <br /> ITE NAME AGENCY CONTACT Awka;c t/ � <br /> re4Ie <br /> /bio�r-a�o,► �e d/a74r <br /> � �/ r / y A PHONE ��/o - ,�6 <br /> DRESS , !L Mie /l0lf� OT O/'M���d. gQ./AC�r F AC. APN # ego/- <br /> ITY ZIP <br /> BILLING / RESPONSIBLE, PARTY INFORMATION / (' <br /> AME /�iG`fi" t (�`f �g,/QC7T/-iC 41 Y -Y — Ao r <br /> (LING ADDRESS 3 7,s ND if j ✓u� r` �7v <br /> ITY �/T/ct/�i�-- TATE !P 97-� <br /> ONTACT NAME �� G//JG�-tT Lee HONE /r/D, -7 <br /> PROPERTY OWNER/OPERATOR <br /> AME ?6- oc -(/"-r ?/-"/"r <br /> /- /"c 1i'bn of-s4ra HONE (S/d) 746-42-f2 <br /> DRESS �7� �. L,aAe �u.�� 170 <br /> ITY f✓.cA, e' '-ee,([ TATE r-A IP <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> AME 1, <br /> HONE <br /> DRESS <br /> ITY IS <br /> 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 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, 1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, ACKNOWLEDGE THAT ALL SITE AND/OR PROJECT SPECIFIC <br /> PNS/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 /> AME %itf%e�� S- 15 /n h7Cch ls#1 :�'Z4-84-s6z6 <br /> iGNATURE JATE /D <br /> OMPANY �G9`� � iJiCuf Q��Ca�t�/Ysf' JPS✓%c�I - <br /> FTCo/ QST, /��r /"u• ��O v <br /> 89.007(IV)12/90BILFRMI2 / <br />