Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />AUTHORIZATION TO RELEASE <br />ANALYTICAL RESULTS <br />GEOTECHNICAL DATA <br />ENVIRONMENTAL/SITE ASSESSMENT' INFORMATION <br />1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT <br />1524 Fresno Ave. Stockton <br />(StreetAddress) (city) <br />HEREBY AUTHORIZE <br />Kiff Analytical <br />ratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR MY <br />REPRESENTATIVE. <br />BUSINESS NAME: Valley Pacific Petroleum Services <br />(ffApplicable) <br />OWNER: Mike Eliason Cardlock Manager <br />(Please Print) (Title) <br />(Owner Signature) (Dale) <br />ADDRESS: 166 Frank West Circle <br />(Mailing Address) <br />Stockton CA 95206 <br />(City) (State) (Zip Code) <br />PHONE:( ... 209 ) 993-8793 <br />EH23046 (Revised 07/21/10) <br />N. <br />