Laserfiche WebLink
ti RE�� <br /> S1._ AITIGATION ACKNOWLEDGMENT/REQUEST FOR SERVI FORM <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL b 0 S10N <br /> SITE INFORMATION <br /> THER LEAD AGENCY <br /> ITE NAME <br /> �D SPC C.Y1�v <br /> AGENCY CONTACT <br /> PHONE <br /> DRESS M 1 5S(p vn i�( �� �,kccV-1 eCG, C R• APN # J <br /> ITY �k&,4e_Cox , CA- ZIP <br /> BILLING / RESPONSIBLE PARTY INFiORMATION <br /> AME 1 Yl } I�OG(�' ✓s <br /> ILING ADDRESS G• <br /> ITY 5-7A_Q ?) �• N TATE �AIzip a`4c v J <br /> ONTACT NAME C I ✓)-� P O �S :'HONE -24 1 J/ 3 t•}• _ <br /> PROPERTY OWNER/OPERATOR // ,/G <br /> AMElip" Q✓I Y pl /L HONE -71 �70 5:3 Z r <br /> DRESS <br /> ITY rC« . TATE C p I P 2 <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> AME ^-��"�Y �T' it� HONE <br /> DDRESS <br /> ITY TATE I IP <br /> JUN <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT;,,IRONMENTALHEA.LTH <br /> P Ef-,�-M,'T IS[-rVICES <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, I, 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 sho no ZLIGC <br /> IGNATURE 4-�/ �v FAE <br /> OMPANY Lyt v//D,lm ell? �P�'V/�'c�o ITLE CPI�IO� 66 /J/ <br /> 89-007(IV)12/90BILFRMI2 <br />