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SITE —IGATION ACKNOWLEDGMENT/REQUEST FOR SERVICES FORM <br /> SAN JOAQUIN (�Y • PUBLIC HEALTH SERVICES/ENVIRONMENTAL H' TH DIVISION (l / <br /> SITE .INFORMATION THE LEALr AGENCY i� <br /> (� �O� 1 n l/ AGENCY CONTACT <br /> ITE NAME L,QflJM f CdA 7` - - <br /> PHONE <br /> Weber <br /> 1 l,� ` APN 0 <br /> DRESS a D�S� Weber Jrce+ <br /> IF 7 0� <br /> ITY sioc� 0 1 CA <br /> BILLING / RESPONSIBLE PARTY INFORMATION _ <br /> AHE f <br /> AILING ADDRESS <br /> HE <br /> �--- <br /> LTATED- <br /> 'ITY <br /> P <br /> OHTACLNAME] <br /> ^� <br /> PROPERTY OWNCR/OPERATOP. --- <br /> ONE <br /> AME baN - <br /> DRESS f 1 _ TATE IP I � <br /> ITY - - - <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOU - <br /> ""- HONE <br /> AM2 <br /> DRESS IP <br /> -TATE IP ^ <br /> ITY - s <br /> �fPAYMENT <br /> RECEIVED <br /> AUTHORITATION TO RELEASE/BILLING ACKNOWLEDGEMENT <br /> MAR 14 lc'ol <br /> '1 p T, AT THE A60VE SITE ADDRESS HERE6Y <br /> I, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, SAN J0 1 ��IL'Y ML.�' <br /> l pIJTHORI2E THE RELEASE OF ANY AND ALL 1�NALYTICAL RESULTS, GEOT�C�1Q�. ► �ho- 4MEkTAL/SITE ASSESSMENT INFORMATION TO <br /> ENVIRONMEENTAL HEAL i4,,, <br /> SAN JOAOUlk COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL H5ALTH DIVISION AS SOQN AS IT IS AVAILABLE AND A7 THE SAME TIME 1T IS <br /> PROVIDED TO ME OR MY REPRESENTATIVE. <br /> i <br /> ADDITIONALLY, 1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, ACKNOWLEDGE THAT ALL SITE AND/OR PROJECT SPECIFIC <br /> E BILLED TO THE PARTY 1DEN71FIED <br /> PHS/EHD HOURLY CHARGES ASSOCIATED WITH THIS ACTIVITY WILL BABOVE AS THE "RESPONSIBLE PARTY". <br /> I <br /> APPLICANT'S NAME, TITLE, SIGNATURE/DATE <br /> I <br /> i <br /> I AME <br /> I --------------- <br /> IGNATURE ---- <br /> DATE <br /> ITLE ��/unr/t�i?TY�2 <br /> PAGE DNI: OF TWO <br /> i <br /> 89-007(IV)12/9081LFRM12 <br /> 1 <br />