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1L 19:91 14: 11 FAX 415 372 91iu1 IT CORP MARTINEZ zoo2 <br /> SITE MITIGATION AC101"EDGMENT/REQUEST FOR SERVICES FCRM <br /> SITE INFCRNATION SAN JCAQUIN COUNTY • PUBLIC HEALTH SERVICESIENVIR09MENTAL HEALTH DIVISION <br /> THER LEAD AGERCT <br /> T7 <br /> NAME AGENCY CONTACT <br /> Cargill <br /> PHONE <br /> DRESS APN C <br /> Port Road 21, Port of Stockton <br /> rY <br /> Stockton, California IP 95201 <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> KNAME <br /> argill <br /> .O. Box 9300, Department 40 <br /> inneapolis TATE NLd. IP 55440 <br /> erry Keller HONE (612) 475-5422 <br /> PROPERTY OWNER/OPERATOR <br /> AME Port of Stockton HONE 7 <br /> (_09) 946-0246 <br /> DRESS ,2'LUl West Washington Street <br /> ITY $tOCktOn TATE I;A, IP 1 95201 <br /> CLIENT INFORMATION (IF DIFFERENT FROM CWNER/OPERATOR) <br /> AME <br /> Cargill Contact: Sack 901m) HONE (209) 946-0914 <br /> DREss Port Road S ort of Stockton <br /> IfYockron TATE CA. IP 9 201 <br /> AUTHCR:ZATION TO RELEASE/BILLING ACKNOWLEDGEMENT <br /> I, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGEIIT OF SAME, OF THE PROPERTY LOCATED AT THE ABOVE SITE ADDRESS HEREBY <br /> AUTHORIZE THE RELEASE OF ANY AHD ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA ANO/OR ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO <br /> SAN )CAOUIR COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION AS SCON AS IT IS AVAILA3LE AND AT THE SAME TIME IT IS <br /> PRCVIOED TO ME OR MY REPRESENTATIVE. <br /> ADDITICNALLY, I, THE UNDERSIGNED OWNER, CPERATCR, CLIENT,,.OA 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 /> TAME imo y Arenson Ss8 <br /> (GNAT L'RE <br /> LATE 4 <br /> CMPANY IT Corporation _ <br /> tnE Project Manager <br /> 89.007(IV)12/9O0ILFRM12 <br />