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Tr P.C. alto <br /> SITE MITIGATION ACKNOWLEDGMENT/REQUEST FOR SERVICES FORM ��11N 1 1y91 <br /> SAN JOAQUIN COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION (� <br /> SITE INFORMATION //'' THER LEAD AGENCY <br /> Co C� D I(o�,.� AGENCY CONTACT <br /> FITENAME. dd <br /> J e l A-e I I(-D n I / PHONE <br /> WORESS .s f-al x01 <br /> ITY <br /> C ZIP <br /> ILLING <br /> AME -b �/J V t/►"Ciy- <br /> !LING ADDRESS 6 'Di Dr- 2,00 <br /> P <br /> ITY O <br /> TATE I 9 I l 1 <br /> ONTACT NAME <br /> PROPERTY OWNER/OPERATOR <br /> HON£ y <br /> AME �T <br /> Dafss � �_��O �(,3� Gu►.��CvSfi� ✓c� - <br /> 1TY TATE IP S Z3 <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNERIflPERA�TyO�R) <br /> AME GC o s� P, — �f� Lao f CAe0- i' HONE 7 3 SOU� <br /> DORESS <br /> �cc, c f}SCh <br /> QI/1/(.i(,���/` St ^n <br /> ITY D TATE l- ; IP J <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 ENVIRONMENTALISITE ASSESSMENT INFORMATION TO <br /> qAN 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 /> 11 <br /> APPLICANT'S NAME, TITLE, SIGNATURE/DATE <br /> AME lJf <br /> IGNATURE ;:', P0NMENTAL HEALTH <br /> ITLE (4 <br /> PAGE ONE OF Two <br /> 99-007(IV)12/90SILFRM12 `, <br />