Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 4683420 <br /> AUTHORIZATION TO RELEASE <br /> • ANALYTICAL RESULTS <br /> ' GEOTECHNICAL DATA _ <br /> ENVIRONMENTAUSITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> 7 <br /> LOCATED AT I �5 CSI nfbn J u4i I IC/�i pM ffY <br /> (Street Address) (city) <br /> HEREBY AUTHORIZE L204Xd / peI 1T-eCt,F] <br /> (Cabo� or Consultant) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE <br /> BUSINESS NAME: <br /> (If Applicable) <br /> OWNER/OPERATOR: owd DfA l n l bW h�Y <br /> Please Print (Tide) <br /> (Owner/Operator Signature) <br /> ADDRESS: <br /> 14496 Clin+on '�Ow�h <br /> (Mailing Address) <br /> RIpDn CPP 0,5 5W <br /> q(City) (State) (Zip Code) <br /> PHONE: <br /> DATE: <br /> EH 23 041 (Revised 7-10-92) Page 9 <br />