Laserfiche WebLink
SITE CTION ACKNOWLEDGMENT/REQUEST FOR SERVICES <br /> SAN JOAQUIN COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE...iH DIVISION <br /> SITE INFORMATION <br /> THER LEAD AGENCY <br /> ITE NAME Unocal Service Station No. 6981 AGENCY CONTACT <br /> PHONE <br /> DDRESS 4707 Pacific Avenue APN e <br /> ITY Stockton IP <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME Unocal Corporation <br /> AILING ADDRESS P.O. Box 5155 <br /> I-ITY Sail Raiion STATE i CA IP 1 94583 <br /> 4583I <br /> -ONTACT NAME Penny S1 l Zer HONE (510) 277-2320 <br /> PROPERTY OWNER/OPERATOR <br /> AME Unocal Corporation HONEFT510) _ <br /> DDRESS P.O. Box 5155 <br /> TY San Ramon TATECA IP �3 <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> ,AME RESNA Industries/Applied Geos stems Inc. HONE 916 852-6690 <br /> DDRESS 3164 Gold Camp Drive, Suite 200 <br /> ITY Rancho Cordova CA TATE I <br /> A4}}pp A IP 195670 <br /> t M <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT C EI 1992 <br /> E D <br /> 1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, OF THE PROPERTY LOCATED AT THE AS VE TE 'ADDRESS HEREBY <br /> SAN JOA U COUNTY <br /> AUTHORIZE THE RELEASE OF ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR ENVIRawakt V* RWW3NFORMAT ION TO <br /> ENVIRON IAL HEAL DIVISION <br /> SAN JOAQUIN COUNTY PUHLIC 1iEAL-hi SERVICES, [N`iiRGNNENTAL HEALTH DIVISION AS SOON AS IT IS A' ILADLE. AND AT T. 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 /> APPLICANT'S NAME, TITLE, SIGNATURE/DATE <br /> �y <br /> LAME E- S C��r S11 <br /> IGNAlUIE ATE ( '--5 Z <br /> Qj <br /> OMPANY ITLE <br /> 89.007(IV)12/90BILFRMI2 <br />