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SITE ION ACKNOWLEDGMENT/REQUEST FOR SERVICES <br /> SAN JOAQUIN COu.i. - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HE—i H DIVISION <br /> SITE INFORMATION <br /> THER LEAD AGENCY <br /> ITE NAME AGENCY CONTACT <br /> Naval Communication Station Stockton <br /> PHONE <br /> DDRESS APII # <br /> Rough & Ready Island <br /> ITY ,t J�. ?�'a',''�r,�;, <br /> IP <br /> Stockton, CA 95203-5000 <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> AME Naval Communication Station Stockton <br /> AILING ADDRESS Code 33, Bldg 917 , Rough & Ready Island <br /> ITY Stockton TATE CA kP195203-5000 <br /> ONTACT NAME Bruce James HONE (209) 944-0400 <br /> PROPERTY OWNER/OPERATOR <br /> AME Naval Communication Station Stockton HONE 1 (209) 944-0225 <br /> DDRESS Rough & Ready Island <br /> ITY Stockton TATE CA IP 95203-5000 <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> LAME 1PHONE <br /> *DRESS <br /> ITY TATE 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 INFOR14ATION TO <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT TILE 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 /> LAME E. G. MONINGER, CAPT, USN 1S#1 lyS-j __ 31a <br /> I GNATURE ATE AP <br /> OMPANY Naval Communication Station Stockton TITLE Commanding Officer <br /> 89-007(IV)12/90B1LFRM12 <br /> E1,41CL0 9 U PiE <br />