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SI# �TIGATION ACKNOWLEDGMENT/REOUEST.FOR SERV[Cf ORM <br />' Y SAN JOAOU1N i1HTV - PUSLIC HEALTH SERVICES/EHVIROHMENTALW ATH DIVISION i <br /> IIIt NFORMAT ION 3THER LEAD AGENCY <br /> AGENCY CONTACT <br /> ITE NAME j <br /> Canteen Corp. PHONE <br /> i <br /> ' 3 <br /> APN S <br /> DDRESS <br /> 1500 Shaw Rd. <br /> a <br /> IP <br /> Itr 952x5 <br /> Stockton. Ca. <br /> BILLING / RESPONSIBLE PARTY INFORMATION j <br /> AHE Canteen Corp. <br /> AILING ADDRESS 1500 Shaw Rd. - <br /> TATEIP952 <br /> TTY Stockton Ca <br /> I <br /> ONTACT NAME Marc Paschini HONE (209)466-2709 <br /> i <br /> PROPERTY OWNER/OPERATOR <br /> HONE <br /> AME i <br /> %DDRESS <br /> TATE IP ! <br /> (TY <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> HONE <br /> AHE <br /> DDRESS <br /> ITATE IF, <br /> TY <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT . <br /> I, 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 ANO 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, I, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, ACKNO'dLEDGE 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". I <br /> APPLICANTiS NAME, TITLE, SIGNATURE/DATE <br /> I <br /> AME Marc Pasch ini District Manager S <br /> ATE <br /> NATUR <br /> 31 GCA ` <br /> OMPANY ITLE / I <br /> I <br /> 89.407(IV)12/40BILFRMI2 <br />