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E MITIGATION ACKNOWLEDGMENT/REQUEST FOR SE ES FORM <br /> SAN JOA6.,N COUNTY - PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEALTH DIVISION <br /> SITE INFORMATION <br /> THER LEAD AGENCY &Ak �G1(�CR <br /> 1 TE NAME Z,�/�� ,(_s be����. AGENCY CONTACT r <br /> ii �rar PHONE p�'�'—a / �/T 7 <br /> DRESS /n4grsea"wi dl6ili&le F� (/L�. OW t!`I�K /�u APN /O <br /> ITY �� IP <br /> BILLING / RESPONSIBLE PARTY IINFORMATION /_ <br /> AME p-c, <br /> 'T•t GIS � ,FIeG-trk- �OM�a«y- (Tar pr'J.41-oa, 't- 5mac <br /> OILING ADDRESS STS A1041 lt), IMAIC Scale f 70 <br /> ITY Npin-cT Cre-clC TATE e/¢ IP 9454$ <br /> ONTACT NAME /9/-- CrneEf F Lec HONE (r-lo) 746 -42 f-2- <br /> PROPERTY OWNER/OPERATOR <br /> AMEf r ,, }- (ras HONE <br /> DRESS :g-IV JV• (,Ji f+ �4te Sti, �7J <br /> ITY w0.�Kw+ ClCC(L TATE IP �f 4SS9 <br /> CLIENT INFORMATION (IF DIFFERENT FROM OWNER/OPERATOR) <br /> AME HONE <br /> ODRESS <br /> ITY TATE IZ IP <br /> AUTHORIZATION TO RELEASE/BILLING ACKNOWLEDGEMENT <br /> 1, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, OF THE PROPERTY LOCATED AT THE ABOVE SITE ADDRESS HEREBY <br /> AUTHORIZE THE RELEASE OF ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA ANO/OR ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS <br /> PROVIDED TO ME OR MY REPRESENTATIVE. <br /> ADDITIONALLY, I, THE UNDERSIGNED OWNER, OPERATOR, CLIENT, OR AGENT OF SAME, ACKNOWLEDGE THAT ALL SITE AND/OR PROJECT SPECIFIC <br /> PHS/EHD HOURLY CHARGES ASSOCIATED WITH THIS ACTIVITY WILL BE BILLED TO THE PARTY IDENTIFIED ABOVE AS THE "RESPONSIBLE PARTY". <br /> APPLICANT'S NAME, TITLE, SIGNATURE/DATE <br /> AME -Al`-W1I S- All'-15 wdoll ls#1 6-24 84-S-62-t7 <br /> IGNATURE G'1;LC���. ��' [ATTE /D -Zq'92 <br /> OMPANY �� - T��Ai 0� a�(� JCI'✓ICCs 6Ff !TLE 16mil,'C'75;/�TjCGo IC <br /> a . b-2-7:> <br /> 89.007(IV)12/90BILFRMI2 <br /> r <br />