Laserfiche WebLink
SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 tax: (209) 468-3433 <br />AUTHORIZATION TO RELEASE <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL, DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, TI -M UNDERSIGNED OWNER ANDIOR OPERATOR OF THE PROPERTY AND/ORFACILITY LOCATED AT <br />1553 Colony_Rd Ripon <br />(Street Address) (City) <br />HEREBY AUTHORIZE <br />64LfEc H ENU(gayrA :&r1A— _. (Labo <br />ratniy) <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: Love's -Travel <br />(IfApplicable) <br />OWNER: Kevin Nickell for Love's Travel Stops of California Environmental Divisions Manager <br />l / (Please Prt»t) (Title) <br />03/12/14 <br />(Owner Signature) (Date) <br />ADDRESS: <br />PO Box 26210 <br />(Halling Address) <br />Oklahoma City OK 7312E <br />(City) (State) (Zip Code) <br />PHONE: ( 405 )_ 242-2455 <br />EH 23 046 (Revised 07/21/10) <br />6 <br />