Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> (209)468-3420 <br /> AUTHORIZATION TO RELEASE <br /> *ANALYTICAL RESULTS <br /> *GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORiMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> (Labor ory) <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 TIME IT IS PROVIDED TO ME OR vfY <br /> REPRESENTATIVE. <br /> BUSINESS NAME: 17`z LoD l`' w1 J C <br /> (If Applicable) /� / <br /> OWNER/OPERATOR: �r EAIW j� �/�� ��/l� !'�`l��L / 6-� <br /> (Please Print) (Title) <br /> z/ « o� <br /> caner/Oper r Signatur ! (Date) <br /> ADDRESS: �d2 <br /> (Mailing Address) <br /> 190 <br /> (City) (State) (Zip Code) <br /> v <br /> PHON ��E:. 3 APr D e EK <br /> EH 23 046 (Revised 3/15/02) Page 9 <br />