Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> (201))468-3420 <br /> �j A- AUTHORIZATION TO RELEASE <br /> ` A.NAL1'TT('AI. Rt-'SUI.TS <br /> (;fiOTI•('HNI('AL DATA <br /> ENVIRONMENTAUSITF ASSESSMENT INFORMATION <br /> 1,THE UNDERSIGNFD OWNER AND/OR OPERATOR OF THF PROPERTY AND/OR FACILITY <br /> LOCATED AT <br /> (Street Addrevs) <br /> (Citi') <br /> HEREBY AUTHORIZE <br /> (�boratorfy <br /> TO RELEASE,ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTALHE <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THI• SAME_ ALTH <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE <br /> BUSINESS NAME <br /> (l/rl pplieuhh•) <br /> OWNFR/OPERATOR <br /> (P/c'uve Print/ <br /> (Tide) <br /> (o'er/0perat0r Signature) <br /> (Date) <br /> ADDRESS: <br /> (Muilirn1,l ddrerv) <br /> Will.) (Stu/e) !7ip Code/ <br /> PHONE: ( ) <br /> EH 23 046 (Revised 1/24/(12) <br /> 6 <br />