Laserfiche WebLink
Oct 02 08 11:38a Reliable Petmieum 209-845-8953 p,7 <br /> 't ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> AUTHORIZATION TO RELEASE <br /> *-ANALYTICAL RESULTS <br /> *GEOTECEINICA,L DATA <br /> * ENVIRONMENTAUSITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR Of THE PROPERTY ANDIOR FACILITY <br /> LOCATED AT <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> (Laboratory') <br /> TO RELEASE ANY AND ALL ANALYTICAL 1NFORMATIONTO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS ITIS AVAILABLE,AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MV REPRESENTATIVE. <br /> BUSINESS NAME: <br /> llfApplicable) <br /> OW NER/OPEF-ATOR: <br /> (Please,Print) (Title) <br /> (Owner/Opera ter Signature) (Date) <br /> ADDRESS: <br /> (Mailing Address) <br /> (City) (State) (Zip Code) <br /> PHONE:[ ) <br /> EI 1213 046 (Reprised V-1/07) <br /> 4 <br />