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SIlo TIGATION ACKNOWLEDGMENT/REQUEST FOR SERVI DORM <br /> SITE INFORMATION /�/ , RED <br /> JOAOUIN LUUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION l <br /> THER LEAD AGENCY RVA4 991 <br /> ITE NAME AGENCY CONTACT ,�A <br /> L <br /> PHONE <br /> DRESS _ APN k <br /> ITY <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME C `I <br /> (LING ADDRESS <br /> ITY G�LJ��j� TATE j:�AN S, IP 202 <br /> ONTACT NAME A HONE q)S) 3(, 2 Ion <br /> PROPERTY OWNER/OPERATOR T/ <br /> AME HONE 2 �� <br /> DRESS <br /> 'I TY TATE <br /> CLIENT INFORMATION OF DIFFERENT FROM OWNER/OPERATOR) <br /> AME <br /> HONE <br /> DRESS <br /> ITY TATE IP <br /> ,gECEaVE <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENTr�:�'� <br /> I, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, ' ` ( (� 1 r' <br /> r(fJ§��'�N�P�':b��KH�Er:�IjWERTY LOCATED AT THE ABOVE SITE ADDRESS HEREBY <br /> �QQICN�gU��4� <br /> AUTHORIZE THE RELEASE OF ANY AND ALL ANALENANA I TECHNICAL 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 /> ���� \\ y� r O 1h4R.L- ,. 4cx I a4 <br /> AME N L1�C'i Fes . L/«� S \ <br /> IGNATURE <br /> ITLE �1Z /DATE Z3 <br /> 89-007(IV)12/90BILFRM12 <br /> -3 , q1 <br />