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TPR 7t)13r <br /> SITE MITIGATION ACKNOWLEDGMENT/REQUEST FOR SERVICES FORM -CLJ U b b ? 7 6 / <br /> SAN JOAQUIN COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION �b <br /> SITE INFORMATION <br /> OTHER LEAD AGENCY CVRW CB <br /> ITE NAME AGENCY CONTACT Karen Be <br /> DDRW-Tracy <br /> PHONE (916) 255-306 <br /> DORESS APN a 252-07-02/250-20--06 <br /> 25600 Chrisman Rd <br /> ITY IF <br /> Tracy CA 95376 <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> aME Montgomer Watson <br /> ILING ADDRESS 4525 South Wasatch Blvd, Suite 200 <br /> ITY Salt Lake City TATE UT <br /> ONTACT NAME Sue Spencer HONE 801 273-2412 <br /> PROPERTY OWNER/OPERATOR <br /> AME PHONE (209) 982-2086 <br /> Defen T <br /> DRESS DDRW-Sh r e <br /> ITY Lathrop <br /> TATE I IP <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> AXE HONE <br /> DRESS ` <br /> ITY 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 A80VE 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-SAMETIME 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 /> PNS/EHO HOURLY CHARGES ASSOCIATED WITH THIS ACTIVITY WILLBEBILLED TO THE.PARTY IDENTIFIED ABOVE AS THE "RESPONSIBLE PARTY". <br /> APPLICANTIS N E, TITLE, SIGNATURE/DATEE� (/� <br /> AME I I �I�,I .I-�S '� SN <br /> IGNATURE ATE 7pp/n/'� <br /> OMPANY ',����q <br /> 89.007(IV)12/90BILFRMI2 <br />