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N SITE INFORMATION SITETION ACKNOWLEDGMENT/REQUEST FOR SERVICES SAN JOAQUIN C* Y - PUBLIC HEALTH SERVICES/ENVIRONMENTAL H DIVISII mm BILLING / RESPONSIBLE PARTY INFORMATION PROPERTY OWNER/OPERATOR CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) S AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT I, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, OF THE PROPERTY LOCATED AT THE ABOVE SITE ADDRESS HEREBY AUTHORIZE THE RELEASE OF ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. ADDITIONALLY, I, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, ACKNOWLEDGE THAT ALL SITE AND/OR PROJECT SPECIFIC PHS/END HOURLY CHARGES ASSOCIATED WITH THIS ACTIVITY WILL BE BILLED TO THE PARTY IDENTIFIED ABOVE AS THE "RESPONSIBLE PARTY". APPLICANT'S NAME, TITLE, SIGNATURE/DATE PAGE ONE OF TWO 84-007(IV)12/4081LFRM12 t :ONTACT NAME .� Jim PROPERTY OWNER/OPERATOR CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) S AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT I, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, OF THE PROPERTY LOCATED AT THE ABOVE SITE ADDRESS HEREBY AUTHORIZE THE RELEASE OF ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. ADDITIONALLY, I, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, ACKNOWLEDGE THAT ALL SITE AND/OR PROJECT SPECIFIC PHS/END HOURLY CHARGES ASSOCIATED WITH THIS ACTIVITY WILL BE BILLED TO THE PARTY IDENTIFIED ABOVE AS THE "RESPONSIBLE PARTY". APPLICANT'S NAME, TITLE, SIGNATURE/DATE PAGE ONE OF TWO 84-007(IV)12/4081LFRM12