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i . <br />1 <br />SITE MITIGATION OR STATEMENT ACKNOWLEDGEMENT/REQUEST FOR SERVICES <br />LETTER OF AC"6WLELGEMENT: <br />TO: SAN �OAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHO) <br />445 N. SAN JOAQUIN ST. <br />P. 01 SOX 2009 <br />STOCXTON, CA 95201 <br />FROM: —r;��� (property <br />owner Jna e <br />RE: <br />WWIA6 <br />owner ma <br />aaaress <br />S, F14maN IGA-Obo+ <br />(city, state, ZIP) <br />I <br />I(We) declarei that the activity being performed at the above <br />referenced site is being conducted with my(our) knowledge and <br />approval. Furthermore, I(we) acknowledge that payment of PHS-EqD <br />charges will become my(our) responsibility in the event said <br />ch� e not paid by the client and/or operator identified on <br />e attac ed "Site Mitigation Acknowledgement/ Request for Services <br />Fa "S,tatement <br />Acknowledgement/ Request for Services Form". <br />(signature an <br />LC%ACKN.FRM <br />e <br />-'�) C -,7-- <br />(phone nui <br />32 ---- <br />(date) <br />_ d L I: b 1 7.5/r•?%C) i <br />