Laserfiche WebLink
i <br /> • SITE MITIGATION ACKNOWLEDGMENT/REQUEST FOR SERVICES FORM <br /> SAN JOAQUIN COUNTY • PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISIOa <br /> SITE INFORMATION <br /> THER LEAD AGENCY <br /> ITE NAME &-'i Lk h be j4gv S AGENCY CONTACT <br /> PHONE 'WK I - <br /> DRESS �•^� 2 �� � `_�•. � APN # <br /> ITY IPTM <br /> �C <br /> BILLING / RESPONSIBLE PA Y INFORMATIONJ <br /> AME <br /> pol#x�� <br /> iLING ADDRESS 1) <br /> TATECA— IP a3O <br /> ol <br /> ONTACT NAME �'vI C� HONE 41,;-(oqo- 4-32 <br /> PROPERTY OWNE /OPERATOR <br /> AME NO 01 <br /> 2 <br /> DRESS <br /> :kD <br /> ITY TATE IP V <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> LAME HONE <br /> DRESS <br /> ITY TATE IP <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT s <br /> 1, 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 /> DHS/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 1sS#1 <br /> IGNATURE ATE <br /> OMPA1Y 5 MC} ITLE V\%T. <br /> PAGE ONE OF TWO <br /> 89.007(IV)12i"64,LFRM12 <br /> EH 29 01 <br />