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• SITE MITIGATION ACKNOWLEDGMENT/REOUEST FOR SERVICES FORM <br /> SAN JOAQUIN COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> SITE INFORMATION <br /> THER LEAD AGENCYRWQCB 5, EPA 9 <br /> Defense Distribution Region West-Tracy Facility RW <br /> ITE NAME Remedial Investigation AGENCY CONTACT QCB James Taylor <br /> PHONE 916/255-3065 <br /> 25600 South Chrisman Road, Tracy, CA <br /> DDRESS APN N <br /> [TY Tracy, California IP 95376 <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME Montgomery Watson <br /> AILING ADDRESS 365 Lennon Lane <br /> TYWalnut Creek TATE CA P 94598 <br /> ONTACT NAME Sue Tiffany, P.E. , Project Manager HONE 510/975-3400 <br /> PROPERTY OWNER/OPERATOR <br /> AME Defense Logistics Agency (contact Marshall Cloud) HONE 209/982-2086 <br /> DDRESS DDRW-Sharpe, (Roth Rd, Lathrop, CA) PO Box 96001 <br /> ITY Stockton iSTATE I CA 1P 95296-0250 <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> AME Same as above HONE <br /> DDRESS <br /> ITY TATE I IP <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 /> PNS/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 Sue Tiffany, P.E. ISS# <br /> IGNATURE ATE Iv <br /> OMPANY Montgomery Watson ITLE Project Manager <br /> SWI <br /> 89.007(IV)12/9OBILFRMI2 ,yy �q�����/ <br />