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SITE MITIGATION ACKNOWLEDGMENT/REQUEST FOR SERVICES FORM k <br /> SAH JaAQUIN COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> SITE INFORMATION THER LEAD AGENCY <br /> AGENCY CONTACT <br /> • <br /> ITE NAME <br /> Canteen Cori) PHONE <br /> APR 0 <br /> DDRESS <br /> 1500 Shaw Rd <br /> IP <br /> ITY 95205 <br /> Stockton Ca. <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> )AHE canteen Core <br /> tAILING ADDRESS 1500 Shaw Rd <br /> TATF Ca IP <br /> TY StoC k 0-n <br /> ONTACT NAME Marc Paschiri HONE (209)466-2709 <br /> PROPERTY OWNER/OPERATOR <br /> NONE <br /> )AMC <br /> DORES9 1� � w Z <br /> TATE IP � <br /> ITY <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> HONE <br /> • )AME <br /> %DDRESS <br /> TATE IP ' <br /> ITY <br /> AUTHORIZATION 10 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 AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AHD/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, 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 /> APPLICANIIS NAME, TITLE, SIGNATURE/DATE <br /> )AHE Marc Pasch>_ni District Manager s# 7 �j <br /> IGNATURE G <br /> OMPANY /L 111LE ' <br /> 89 O07(IV)12/9O8ItFRM12 <br />