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SlITIGATION ACKNOWLEDGMENT/REQUEST FOR SERVICEFORM <br /> SITE INFORMATION SAN JOAQUIN COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> THER LEAD AGENCY <br /> ITE NAME ""•-'J <br /> AGENCY CONTACT <br /> //,/ PHONE <br /> DDRESS l/ �G R� PiIV,6r &, <br /> w APN # �1'7 <br /> !TY 6TG/C'/�/D/� 1P <br /> BILLING / RESPONSIBLE PA <br /> RTY <br /> yINFORMATION <br /> 7�/VEY <br /> �' / TATE 4A IP''� HONE <br /> PROPERTY OWNER/OPERATOR <br /> AME t-/"ON C- _NATIONAL. V <br /> �iV CES 1:::1717-�vliL 17 <br /> DDRESS 1�lve� <br /> ITY �a p;7 � H <br /> �1J/-// C' 7'J,�.. <br /> TATE ^/'i /��./J ' -,A�i <br /> CLIENT INFORMATION (IF DIFFERENT FROM IP -, ".JL/OWNER/OPERATOR) <br /> AME <br /> HONE <br /> DRESS <br /> ITY <br /> PTATTE- 1 1p <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT <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, 1, 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 3�7 <br /> AME Mt�vl� �C� S# <br /> IGNATURE , <br /> ATE <br /> OMPANY ��t. ��✓�Pr J� <br /> TITLE <br /> PAGE ONE OF TWO <br /> 89.007(IV)12/90BILFRMI2 <br /> EH 29 01 <br />