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S1IL VITIGATION ACKNOWLEDGMENT/REQUEST FOR SERVI&V4ORM <br /> SITE INFORMATION Y} <br /> SAN JOAQUIN COUNTPUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> THER LEAH AGENCY <br /> ;ITE NAME Beacon Stat Ill o n #641 <br /> } AGENCY CONTACT <br /> 1} ,1 <br /> } PHONE <br /> DDRESS 1210 East Hammer Lane APN # 4 <br /> :i <br /> [rY Stockton , California 7? TA qR" <br /> BILLING /-RE9PONg1-8L-E-'ARi*- INFORMATION _.— <br /> Ann <br /> 9 <br /> AME EVAX Technologies Inc . ENVIRONI'IENTAL HE-ALTH <br /> AILING ADDRESS <br /> 269 Mount Hermon Road <br /> ITY Scotts Valley TATE Calif . �ip 95066 <br /> ONTACT NAME Thomas E . Armstrong HONE ext . 115 <br /> PROPERTY OWNERAOPFAA70R-. <br /> AME Ultramar Inc . HONE 209-582-0241 <br /> DREss 525 West Third Street <br /> 'I TY Hanford TATE Ca , IP 93230 <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> AME HONE <br /> DRESS <br /> ITY TATE I? <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT- <br /> 1, THE UNDERSIGNED 0,yP,fER, gfPX% , 1XLM R, OR AGENT OF SAME, OF THE PROPERTY LOCATED AT THE ABOVE SITE ADDRESS HEREBY <br /> AUTHORIZE THE RELEASE OF ANY AND ALL ANALYTICAL.3RESULTS, 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 /> 1 <br /> ADDITIONALLY, I, THE UNDERSIGNEDkRX OPDfXA5[gp, XIII , OR AGENT OF SAME, ACKNOWLEDGE THAT ALL SITE AND/OR PROJECT SPECIFIC <br /> PHS/EHD HOURLY CHARGES ASSOCIATED WITH THIS ACTII VITY WILL BE BILLED TO THE PARTY IDENTIFIED ABOVE AS THE "RESPONSIBLE PARTY". <br /> t <br /> APPLICANT'S NAME, TITLE, SIGNATURE/DATE <br /> AMEThoma E . Armstron <br /> ,i s# <br /> 1GNATURE ATE 28 march 1991 <br /> 0MPANY EVAX Technologies Inc !' 1TLE Project Engineer <br /> 89-007(IV)12/90BILFRM12 I <br />