Laserfiche WebLink
MITIGATION ACKNOWLEDGMENT/REQUEST FOR SEP" FORM <br /> SITE INFORMATION <br /> SAN JOA OUNTY . PUBLIC HEALTH SERVICES/ENVIRONMEMWEALTH DIVISION <br /> THER LEAD AGENCY <br /> SITE NAME Nestle Warehouse AGENCY CONTACT <br /> PHONE <br /> oDRESS 4343 East Fremont Street APN # 143-280-39 <br /> ITY Stockton, California IP 95208 <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME Giles Engineering Associates, Inc. <br /> AILING ADDRESS 4875 East La Palma Avenue, Suite 607 <br /> Anaheim <br /> ITY TATE I CA Ip 92807 <br /> ONTACT NAME Gregory K. Mitchell HCNE (714) 779-0052 <br /> PROPERTY OWNER/OPERATOR <br /> AME Nestle USA, Inc. HONE 1 818 549-61 7 <br /> DDRESS 800 North Brand Boulevard <br /> TY Glendale ISTATE I CA IP 1 91203 <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> AME Smart 6 Final HONE (213) 584-7301 <br /> "DRESS 4700 South Boyle Avenue <br /> ITYLos Angeles TATE CA IP 1 90058 <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT <br /> I, 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 /> 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 /> AME Gregory K. Mitchell g# <br /> IGNATu ATE11-2-94 <br /> OMPANY I Giles Engineering Associates, Inc. ITLEBranch Manager <br /> 89-007(IV)12/90BILFRM12 <br /> EH 29 01 <br />