Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DMSION <br /> (209)468-3420 <br /> AUTHORIZATION TO RELEASE <br /> * ANALYTICAL RESULTS <br /> * GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMAT ON <br /> T1IS PAGE TO BE SUBMITTED BY KLEINFELDER <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTYA /OR FACILITY <br /> LOCATED AT <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION S JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVI SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTA <br /> BUSINESS NAME: 0 U) <br /> (if Applic e) �y <br /> OWNER/OPERATOR: E `^w LEP, <br /> 717 <br /> (Ilt/e) <br /> (0 <br /> er Aerator Signature) e) <br /> ADDRESS: S <br /> 171iling Address) <br /> (City) (State) (Zip Cade) <br /> PHONE: ( a4e> 4 3�-_' <br /> EH 23 046 (Revised 10/19/98) Page 9 <br />