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SITE NITIWTION ACKHMUDGMENT/REOUEST FOR SERVICES FORK <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> 111E INFORMATION <br /> t. <br /> L THEN LEAD AGENCY <br /> ITE NAME AGENCY CONTACT <br /> Panella Family Trust <br /> PHONE <br /> DRE$s 2150 E. Fremont St. <br /> AP11 I <br /> 1 I <br /> I I <br /> i <br /> :IrY Stockton, Ca. IP 95205 <br /> 81ttI110 / RESPONSIBLE PARTY INFORMATION <br /> M <br /> LAME Robert and Dorothy Panella Owers of Robert and Dorothy Panella Family Trust <br /> I u1L1N0 ADDRESS 5000 E. Fremont St. f <br /> :TIT Stockton', FATE Ca, IP 95215 <br /> :oH1Acr NAME Art Pratt 11411E (209}943-•5000 <br /> PROPERIT UWIER/OPERATOR <br /> fAHE Panella Family Trust 'HONE (209)943-5000 <br /> DDRESS 5000 E. Fremont St. <br /> :Try Stockton TATE Ca. IP 95215 <br /> ;CLIENT INFORMATION (Ir DIFFERENT fACII WNER/OPERATCR) <br /> Same As Ahove <br /> ~ INE 110NE . <br /> } <br /> DDRESS <br /> r `.11YISTATE IP <br /> I <br /> 4UFNGRIlATION 10 RELEASE/811.1.1110 ACKNOWI M.FHEN1 <br /> (, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, OF THE PROPERTY LOCATED AT INE ABOVE SIZE ADDRESS HEREBY <br /> LAUTHORIZE THE RELEASE OF ANY A11D:A1.L ANALYTICAL RESULTS, GEOIECHNICAI DATA AND/OR ENVIRONHENFAL/SITE ASSESSMENT INFORITATION TO <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH;SERVICES, ENVIROIIHEIITAL HEALIN DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME 1111E If IS <br /> ;PROVIDED 10 HE OR NY REPRESENTATIVE. <br /> [ADO11IONAtLY, 1, THE UNDERSIGNED OWNER, OPERATOR, CLIE111, Cit AGE11T OF SAME, ACKNOWLEDGE THAT ALL SITE AHD/OA PROJECT SPECIFIC <br /> IPHS/EHD HOURLY CHARGES ASSOCIATED 1F11H 11115 ACTIVITY TIAL BE BILLED 10 IIIE PARTY IDENTIFIEO'ABOVE AS THE "RESPONSIBLE PARIT". <br /> PPIICANI'S NAME, TITLE, SIGHATURE/DATE <br /> rAIIE Robert, Panella sr <br /> rr <br /> ,IGNATURE ATE <br /> �Iamlla Family Trust IIT1.E Owner. . <br /> �5 <br /> r•OD7(IV)I2/9O8ILFRH12 <br /> �� F <br />