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STATEMENT ACK-NOWLEDCMENT'IREOUCST FOR SERVICES FORM <br />SAN Ji.AQUIN COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL WEALTH DIVISION <br />SITE INFORMATION <br />BILLING / RESPONSIBLE PARTY INFO W TION <br />4AME <br />Fl::OCAJ CTS U SA <br />Q,ILING ADDRESS <br />� C) - F i Fjpp <br />F!TY <br />r�✓ON TATE <br />[NTACT NAME <br />45por2POW ! J C>4 ti sctl :,NONE <br />ROPERTY OWNER/OPERATOR <br />4AME <br />'DORESS <br />'ITY TATE <br />IP <br />CLIENT INFORMATION (if DIFFERENT FROM OWNER/OPERATOR) <br />isOC T <br />1932 <br />AUTHORIZATION TO RELEASE/BILLING.ACKNOWLEDGEMENT <br />1, THE UNDERSIGNED VWNER, OPERATOR, CLIENT, CR AGENT OF SAME, OF THE P8010SRT7 <br />AUTHORIZE THE RELEASE OF ANY ANP ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR ENV:qQNmENTAL/STTE as ssktNT--lNFdAMATION TO ­ <br />I <br />SAN .'OAQVIN COUNTY PUBLIC HEALTH SERVICES, EVVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS <br />i <br />PROVIDED TO ME OR MT XtVKtbtKlAl IVE. <br />ADDITIONALLY, 1, THE UNDER31GNE6. OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, ACKNCuLme THAT ALL SITE AND/OR PROJECT SFECIfIC <br />PSS/EHD HOURLY CHARGES ASSOCIATED WITH THIS ACTIVITY WILL BE BILLED TO THE PARTY IDENTIFIED ABOVE AS THE "RESPONSISLE PARTY11. <br />APPLICANT'S NAME, TITLE, SIGWATURj/DATE <br />I <br />4AHE vu <br />�IGNATURE 4L" JATE <br />PANY A515-R9UA-F re -5 ITLE [�wac7r 6czA?pwA-rotz- <br />89-D07(IV)12/908ILFAM12 <br />EN 23 029 <br />c * d C, I : - 1 _6 E.:3 -.1 Cl 1 [40 d j <br />