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SITE INFORMATION <br />ENT ACKNOWLEDGMENT/REQUEST FOR SERVICES f0 <br />Ul cOUNTY PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br />TH.R LEAD AGENCY <br />'AGENCY CONTACT <br />APN � <br />ITY M1�I�ITGG'/r"+' IP <br />BILLING / RESPONSIBLE PARTY INFORMAtION <br />PROPERTY OWNER/OPERATOR <br />G1 <br />riv I TaTE IP <br />CLIENT INFORMATION (If DIFFERENT FROM OWNER/OPERATOR) <br />DRESS <br />ITY I TATE I yft_ <br />OCT ?,7 1992. <br />AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT SA N Ja j <br />Plial i! }i Qr M L °'7, rn:IT , <br />1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT Of SAME, OF THE PROPERTY LOCATEAVIR@01410 ki A$iD"RE;,$HEREBY <br />AUTHORIZE THE RELEASE OF ANY AMC ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR ENVIRONMENTAL/SITE ASSEEk 'SUPf°T IRMATION TO <br />SAN JOAQUIN COUNTY PUBLIC HEALTI( SERVICES, ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS <br />PROVIDED TO ME OR MY REPRESENTATIIVE. <br />AOOITJONALLY, 1, THE UNDERSIGNED; OWNER, OPERATOR, CLIENT, OR AGENT OR SAME, ACKNO1JLEDGF THAT ALL SITE ANO/OR PROJECT SPECIFIC <br />PNS/EHD HOURLY CHARGES ASSOCIATED WITH THIS ACTIVITY WILL BE BILLED TO THE PARTY IDENTIFIED ABOVE AS THE "RESPONSIBLE PARTY11, <br />i <br />J <br />89.007(IV)12/90BILFAM12 <br />EH Z3 029 <br />I <br />I <br />IC. 'd 81:tl ZG/27/n! <br />14 1) 8 4 <br />f „. w ,�� <br />•rte <br />.Y <br />PROPERTY OWNER/OPERATOR <br />G1 <br />riv I TaTE IP <br />CLIENT INFORMATION (If DIFFERENT FROM OWNER/OPERATOR) <br />DRESS <br />ITY I TATE I yft_ <br />OCT ?,7 1992. <br />AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT SA N Ja j <br />Plial i! }i Qr M L °'7, rn:IT , <br />1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT Of SAME, OF THE PROPERTY LOCATEAVIR@01410 ki A$iD"RE;,$HEREBY <br />AUTHORIZE THE RELEASE OF ANY AMC ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR ENVIRONMENTAL/SITE ASSEEk 'SUPf°T IRMATION TO <br />SAN JOAQUIN COUNTY PUBLIC HEALTI( SERVICES, ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS <br />PROVIDED TO ME OR MY REPRESENTATIIVE. <br />AOOITJONALLY, 1, THE UNDERSIGNED; OWNER, OPERATOR, CLIENT, OR AGENT OR SAME, ACKNO1JLEDGF THAT ALL SITE ANO/OR PROJECT SPECIFIC <br />PNS/EHD HOURLY CHARGES ASSOCIATED WITH THIS ACTIVITY WILL BE BILLED TO THE PARTY IDENTIFIED ABOVE AS THE "RESPONSIBLE PARTY11, <br />i <br />J <br />89.007(IV)12/90BILFAM12 <br />EH Z3 029 <br />I <br />I <br />IC. 'd 81:tl ZG/27/n! <br />14 1) 8 4 <br />