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MITIGATION ACKNOWLEDGMENT/REQUEST FOR SES FORM <br /> SAN JOAQUIN COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENPHEALTH DIVISION <br /> SITE INFORMATION <br /> THER LEAD AGENCY <br /> ITE NAME AGENCY CONTACT <br /> Nestle Warehouse <br /> PHONE <br /> DDRESS 4343 East Fremont Street APN # 143-280-39 <br /> 1T 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 /> Irr <br /> Anaheim TATE CA IP 92807 <br /> oNTACT NAME Gregory K. Mitchell HONE (714) 779-0052 <br /> PROPERTY OWNER/OPERATOR <br /> AME Nestle USA, Inc. HONE fRIRI 549-6157 <br /> DDRESS 800 North Brand Boulevard <br /> ITY Glendale TATE IP 91203 <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> AME Smart 6 Final HONE 1 (213) 584-7301 <br /> DDRESS 4700 South Boyle Avenue <br /> TY Los Angeles TATE CA IP 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 TPE YYE TIRE IT IS <br /> TC ME OR MY REPRESENTATIVE. <br /> +.;,TTI0wALt1, 1, THE U4;EPSI;4ED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, ACKNOWLEDGE THAT ALL SITE AND/OR PROJECT SPECIFIC <br /> PHS/ENO 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 GrgMitchell sp <br /> IGNATU All 1 11-2-94 <br /> -OMI'ANY Giles Engineering Associates, Inc. ITLE Branch Manager <br /> 89.007(IV)12/90BILFRMI2 <br /> EH 29 01 • <br />