Laserfiche WebLink
10/25/2002 10:36 2094683833 FIFTH FLOOR • PAGE 06 <br /> SAN YOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> (209)468-3420 <br /> AUTHORIZATION TO RELEASE <br /> 'ANALYTICAL RESULTS <br /> •GEOTECHNICAL DATA <br /> * ERMONMENTAMTEASSESSMENTTNFORMATION <br /> I THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACIIITY <br /> LOCATED AT // . // <br /> • /, a �A 7^n p <br /> (Street Address) If (City) <br /> HEREBY AUTHORIZE Ad <br /> y o- o r e cl / y <br /> -- Cr e o e n N O 7/7 Q N / 2-� 7-A CC V- ft._-� e. <br /> C (LabG 0. T� c <br /> oratory) <br /> • k . � � Urroryt,c e c <br /> i. <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 <br /> TIME IT IS PROVH)ED TO ME OR MY REPRESENTATIVE. <br /> �o ce � <br /> BUSINESS NAME: 1, 72 :[L7� C /Vrr -a-C Y'O r s <br /> (IfApplieable) <br /> OWNER/OPERATOR: <br /> (Ple/a`sePlfitlJ (Title) <br /> <fa-In-../2 7x� /7.- /G - o 2 <br /> (Owner/ torSigeature) (Date) <br /> ADDRESS: 2 S 3 ✓� &V 9 warn f� V- <br /> (MailingAddr s) <br /> ST/< ),` , chi y52O� <br /> (City) (State) (Zip Code) <br /> PHONE:(. 2,0 9 & 3 3 7 <br /> EH 23 046 (Revised 1/24/02) <br /> 6 <br />