Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <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 <br /> LOCATED AT e 2 <br /> _/Y 5' ra�kTaaJ <br /> (Street Address) (Ci(V) <br /> HEREBY AUTHORIZE s U N s r''¢ 2 ,�/q 13 a n AT0 2 / S <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR MY <br /> REPRESENTATIVE. <br /> BUSINESS NAME: (-' 1'7- Y e K 9"0 14 <br /> (If Applicable) <br /> O�R/OPERATOR: S R US <br /> L" a Past Mr6 100) (please Print) (Title) <br /> Ja - � y3 <br /> (Owner/Operator Signature) (Date) <br /> ADDRESS: e 17- Y //A /- L . ''/zS /I/ • S`T <br /> (Mailing Address) <br /> on( 0 /4 9s,26� - 1947 <br /> (City) (State) (Zip Code) <br /> PHONE:( 02 09 1 9 3 P ?'V6 <br /> EH 23 046 (Revised 10/16/03) Page 9 <br />