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i w <br /> SITE MITIGATION ACKNOWLEDC.XENT/REC(JEST FOR SERVICES FORM <br /> SAN JN)4C1j1N COLINTT • PUBLIC HEALTH SERVICES/ENVIROUM!9TAL HEALTH DIVISICW <br /> SITE INFORMATION HER LEAD AGENCY 17 <br /> SITE NAME AGENCY CCMTACT /yJ, fNQSB�C/fE,Q <br /> YZS UC�I PHONE <br /> APM 0 <br /> DRESS , <br /> IP <br /> ITY ' <br /> BILLING / RESPONSIBLE PARTY INFORMATION <br /> California Army National Guard <br /> iLING ADDRESS P .O. Box 214405 <br /> Sacramento 3TATE CA Ip 195821-0405 <br /> 11Y <br /> TACT NW 2L Joseph W. Horton HONE ( 916 ) 854-3651 <br /> PROPERTY O"ER/OPERATOR <br /> AME SAME <br /> DRESS <br /> TATE IP <br /> ITY <br /> AME <br /> CLIENT INFOPS�lATION (IF DIFFERENT FROM C)"ER/OPERATOR) <br /> UME SAME <br /> HONE <br /> DDRESS <br /> ITT TATE 1P <br /> AUTHORIZATION TO RELEASE/BILLING ACXHOWLEOGM NT <br /> 1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF $K'"E, 01 THE PROPERTY LOCATED AT THE ABOVE SITE ADDRESS HEREBY <br /> AUTHORIZE THE RELEASE OF ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR ENVIRO"ENTAL/SITE ASSESSMENT INFO1WTIL-V TO <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE ASVD AT THE SAME TIME IT IS <br /> PROVIDED TO ME OR MY REPRESENTATIVE. <br /> ADDITIONALLY, 1, THE UNDERSIGNED OWNER,.OPERATOR, CLIENT, OR AGENT OF SAME, ACKNOWLEDGE THAT ALL SITE ANO/OR PROJECT SPECIFIC <br /> PNS/END KouRLY CHARGES ASSOCIATED WITH THIS ACTIVITY WILL BE BILLED TO THE PARTY IDENTIFIED ABOVt AS THE "RESPONSIBLE PARTY". <br /> APPLICANT'S NAME, TITLE, SIGNATURE/DATE <br /> AME COL JAMES R . VANDERVEEN 5 <br /> 1 GHATIRE <br /> ATE 26 JUNE 92 <br /> i Director of Safety and <br /> �°�>NT Cali Guard ITLE Environmental Proa <br /> S�U�-/}'TSI CZE <br /> PAGE ONE OF TWO <br /> I <br />