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 OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT <br />(Street <br />%/ <br />(City) <br />HEREBY AUTHORIZE &w41-1eowoie YTAL 6K SPAKheK le <br />(laboratory or Consultant) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br />HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br />TO ME OR MY REPRESENTATIVE <br />BUSINESS NAME: ?LlE TA?Aey , <br />(IjApplicable) ' <br />OWNER/OPERATOR: <br />DATE: <br />(Please <br />0 <br />(Owner/Operator Signature) <br />ADDRESS: _ -!!5-zo T%�c V Q44/10 <br />(Mailing Address) I <br />PHONE: (20S 83 G 4qz0 <br />EH 23 041 (Revised 7-10-92) Page 9 <br />i T M17"NI <br />(State) (Zip Code) <br />