Laserfiche WebLink
V <br /> 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 <br /> LOCATED AT CC� 0 -\ -, 0<a-- - -Vmc <br /> (Street Addr s (city) <br /> HEREBY AUTHORIZE �r' (�1 �- /j <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 SANIE <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: rd t�V a� -Tr-a-C�/ <br /> (If 4plicable) <br /> OWNER•'OPERATOR: �L 2. k?Lv LL fi%-c4l e- <br /> (Fteasa Print) (T ale) <br /> '!'Owner/Operator Spgnature) <br /> -±) <br /> t Date) <br /> ADDRESS: ,.J� cic <br /> (Mailing Adorers) <br /> Cay)—� St tte) Za Cade; <br /> P40NE: i ( �� <br />