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SITWIGATION ACKNOWLEDGMENT/REQUEST FOR SERVICEORM <br /> SAN JOAQUIN COUNTY • PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> SITE INFORMATION <br /> THER LEAD AGENCY <br /> ( 31TE NAME - AGENCY CONTACT <br /> LUSTRE—CAL NAMEPLATE CORP . <br /> PHONE <br /> DRESS 110 EAST TURNER ROAD APN # <br /> ITY LODI IP <br /> 95240 <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME LUSTRE—CAL NAMEPLATE CORPORATION <br /> (LING ADDRESS P . O . BOX 439 <br /> ITY LODI STATE CA IF 95241 <br /> ONTACT NAME ROD HUNTER HONE 209-334-6263 <br /> PROPERTY OWNER/OPERATOR <br /> AME SEE ATTACHMENT 1PHONE <br /> DDRESS <br /> TV TATE I IP <br /> ` "LIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> AME HONE <br /> DRESS <br /> TV 137ATE IP <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 1S AVAILABLE AND AT THE SAME TIME IT 15 <br /> PROVIDED TO ME OR MY REPRESENTATIVE. <br /> ADDITIONALLY, 1, 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 CONFIDENTIAL <br /> AME JOSEIH C . HOHENRIEDER ISS11 562-60-7794 <br /> IGNATURE ( i--�LATE <br /> :OMPANY d STRE—CAL NAMEPLATE CORP. TITLE CHAIRMAN/CFO <br /> PAGE ONE OF TWO <br /> 89.007(IV)12/90BILFRMI2 <br /> EH 29 01 <br />