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ITE MITIGATION ACKNOWLEDGMENT/REQUEST FOR SERVICES FORM <br /> SAN JOU000UNTY PUBLIC HEALTH SERVICES/ENV I ROMEHEALTH DIVISION <br /> SITE INFORMATION <br /> THEA LEAD AGENCY <br /> ITE NAME gUl-4c -CF.7w„Uoq` <br /> AGENCY CONTACT <br /> Io Nzz ov 5 -r FACLL.NZ LF5 <br /> PHONE `-!/C- se/ SbCe <br /> DRESS APN # <br /> J D� <br /> TY IP <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME F-IAAtCC-ls� A550CI A <br /> (LING ADDRESS 1433 f,� M (z :- kL-\Jv .. <br /> ITY SAC(0,\,OACrpJ"CC> TATE i �.� [P SIS F�z}-. <br /> ONTACT NAME -TF.�C_. L" L rv\ HONE �ZIE> q2b' 33O(n <br /> PROPERTY OWNER/OPERATOR <br /> HErcto r <br /> HONE ZU�j yt7C, G24C <br /> P cN S <br /> DDRESS 2Z0l W WASH wCa <br /> ITY STi7ClG-ruA TATE CA1 VIP <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> AME :>`�UCkTc- "TF=_RiA'LINAL,� 1',CL(a[C.�L C�?MMi T7i--i: NONE -"7./ 3 499 /21?3 <br /> DRESS 7—/'-' Ar2E� PZ0o,)C: S Cc,>Y ['A^J 0S 1AI s—O-04 S7 fce�> 70 <br /> ITY I_OS An(C�L=S TATE �,'{ IP �itX)rj/-OS'7C� <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 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, N, 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 <br /> IGNATURE - 1_ —terr ATEF--/- -7, - q"-- <br /> OMPANT S--bClt_Toh ` �C1 V\NOON�-_ �L;V�-C iti1'Y}eQ ITLf <br /> E-., <br /> 7V)12/90BILFRMI2 <br /> EH 29 01 J U L 0 9 1992 <br /> lip �FNVIRONMENTAL. HF_A.L.l11 <br /> PERM if/Vpvi� <br />