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 OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT �� W e/L . Wg <br /> (Street ddress) (City) <br /> HEREBY AUTHORIZE <br /> (Laborglory 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 /> BUSINESS NAME : <br /> (I Applicable) <br /> OWNER/OPERATOR : N S <br /> (Please Print (Title) <br /> (Owner/OpetVor ignature) <br /> ADDRESS:_ // TOO 'Sl,Ltii v�v S� <br /> (Mailing Address) <br /> -hggxJ-e cA 0/4- <br /> (City) (State) PP) <br /> PHONE: j ) <br /> DATE: <br /> Page 9 <br /> EH 23 041 (Revised 7-10-92) <br />