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SITE INFORMATION AND CORRESPONDENCE
EnvironmentalHealth
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2900 - Site Mitigation Program
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PR0009061
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SITE INFORMATION AND CORRESPONDENCE
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Entry Properties
Last modified
2/27/2019 9:36:29 AM
Creation date
2/27/2019 9:12:35 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2900 - Site Mitigation Program
File Section
SITE INFORMATION AND CORRESPONDENCE
RECORD_ID
PR0009061
PE
2959
FACILITY_ID
FA0004081
FACILITY_NAME
GREAT WESTERN CHEMICAL
STREET_NUMBER
826
Direction
S
STREET_NAME
CENTER
STREET_TYPE
ST
City
STOCKTON
Zip
95203
CURRENT_STATUS
02
SITE_LOCATION
826 S CENTER ST
P_LOCATION
01
QC Status
Approved
Scanner
WNg
Tags
EHD - Public
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SITE MITIGATION ACKNOWLEDGMENT/REOJEST FOR SERVICES FORM <br /> SAN JOAQUIN COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVIS ON <br /> SITE INFORMATION THER LEAD AGENCY <br /> ITE NAME (/� 1 l AGENCY CONTACT <br /> �I/CI IN` ""CS �✓' V� �lM« i4.1 � �^"�� PHONE <br /> A <br /> DRESS PN # <br /> ITY IP <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME 6 /-c "I FOGvC S it <br /> ILING ADDRESS .c^ <br /> ITY rUl �`��� TATE O � IP ( TLUJ <br /> ONT7ACTNAME eQ \ .MvnP f N NE <br /> PROPERTY OWNER/OPERATOR /ix <br /> AME e f \Q w`�� HONE <br /> DRESS Q , , CovA CtiI.er(. c— <br /> q <br /> ITY L�. _ C 4 TATE �'� IP -1 OU ( 'L <br /> CLIENT INFORMATION CIF DIFFERENT FROM OWNER/OPERATOR) <br /> AME .. HONE-lici : <br /> W <br /> DRESS <br /> ITY JUN 2 2 1992 TATE IP <br /> ENVqq�QQN�N� �j� . <br /> FF <br /> �EHm.It( kM�iik <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, I, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR 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 - <br /> AME ✓l (O✓ 7 f C 1-+ <br /> `_ <br /> ATE �f <br /> IGNATURE �J <br /> OMPANY l�.Q 11\LIP- - �- i i G.L-L EEL f 0 C C.{- W <br /> 89-007(IV)12/90HI LFRM72 <br />
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