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MITIGATION ACKNOWLEDGMENT/REQUEST FOR SER FORM <br /> i <br /> SAN JOA COUNTY • PUBLIC HEALTH SERVICES/ENVIRONME HEALTH DIVISION _SITE INFORMATION <br /> THER LEAD AGENCY State DTSC <br /> AME <br /> ITE NAGENCY CONTACT <br /> Lustre - Cal Nameplate <br /> vxoxe <br /> DRESS APN M <br /> 110 E . Turner Road <br /> ITY IP <br /> Lodi , CA . 95240 <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME Lustre - Cal Nameplate <br /> (LING ADDRESS P . O. Box 439 <br /> ITT Lodi TATE IP <br /> I 95241 <br /> ONTACT NAME Rod Hunter HONE 209-334-6263 <br /> PROPERTY OWNER/OPERATOR <br /> AME tjict- reHONE 209-334-6263 <br /> DDRESS P .O. Box 439 <br /> TY TATE IP <br /> Lodi <br /> CLIENT INFORMATION (IF DIFFERENT FRCM OWNER/OPERATOR) <br /> AME HONE <br /> DDRESS <br /> TATE IP <br /> AUTH0912ATION 10 RELEASE/BILLING ACKNOWLEDGEMENT <br /> 1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, OF THE PROPERTY LOCATED AT TIIE 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 JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION ASS AS IT 14 AVAILABLE AND AT THE SAME TIME IT IS <br /> c � i3t <br /> PROVIDED TO ME OR MY REPRESENTATIVE. � 1XV <br /> ADDITIONALLY, 1, THE UNDERSIGNED OWNER,.OPERATOR, CLIEN AGENT OF SAMEE, kkNOWLEDGE THAT ALL SITE AND/OR PROJECT SPECIFIC <br /> PHS/EHD HOURLY CHARGES ASSOCIATED WITH THIS ACTIVITY WILL.8�-IB41Lb il)InnPARTY IDENTIFIED ABOVE AS THE "RESPONSIBLE PARTY". <br /> APPLICANT'S NAME, TITLE, SICNATURE/DATE (2ONMEM�"H „ <br /> AME Mike MCAlexander Str 541-52-74 <br /> IONATURE ( ` ATE 04-28-92 <br /> OMPANY Lustre - Cal Namep ate "" ITLE President <br /> v-007(IV)l2/9OBILFRMI2 <br /> E" 29 01 <br />