Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209)468-3420 <br /> AUTHORIZATION TO RELEASE <br /> * ANALYTICAL RESULTS <br /> * GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER <br /> AND/OR OPERATOR OF THE <br /> PROPERTY AND/OR FACILITY , <br /> LOCATED AT 63 14 I J 67J'Y1P./l�1 J � �Y/f�i/y�.I <br /> (Street Address) ((City) <br /> HEREBY AUTHORIZE .�'f',flE �S't�4 Z!FY7 ,afes! <br /> (Laborntary) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: <br /> (If Applicable) <br /> OWNER/OPERATOR: V J IIPW/ DNJ1�I <br /> (Please Print) (Tile) <br /> �6-9 <br /> (O /Operator Sig re) (Date) <br /> ADDRESS: <br /> (Mailing Address) <br /> (City) (State) (Zip Code) <br /> PHONE: ( ) <br /> EH 23 046 (Revised 10/19/98) Page 9 <br />