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 AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY A <br />LOCATED AT -3L Pf t f. ©" � C <br />r t -F / :'l A` C Q � C A - I F. <br />((Stree�t Address y (City) <br />HEREBY AUTHORIZE sjd�j`L L46-5* , 140,-`r <br />(Laboratory) <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: AlWIL Zfi3c, 66wj. rnj <br />(If Applicable) <br />OWNER/OPERATOR: <br />Print) l (Title) <br />(Owner/Operator Signature) (Date) <br />ADDRESS: 3b ' �l (T�i� I� D o Rj5FT <br />(Mailing Address) <br />5;7y6z�y_T b r1 L-1 15°J05 <br />(City) (State) (Zip Code) <br />PHONE:( 44 1 4Ob <br />EH 23 046 (Revised 9/11/96) Page 9 <br />