Laserfiche WebLink
*10 <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 <br /> I <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT <br /> (Street ddress)1 (City) <br /> HEREBY AUTHORIZE <br /> (Labor ory 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 TO <br /> ME OR MY REPRESENTATIVE. <br /> i <br /> i <br /> BUSINESS NAME : <br /> (/f Applicable) <br /> OWNER/OPERATOR : p-) cQ <br /> (Please Print (Title) <br /> i <br /> (Owner/Ope or ignature) <br /> ADDRESS: // /BUD � <br /> (Mailing Address) <br /> CA- <br /> (City) (State) (Zip) <br /> PHONE: j) <br /> DATE: <br /> Page 9 <br /> EH 23 041 (ReAsed 7-10-92) <br />