Laserfiche WebLink
■► 11! 11911 i <br />, J s <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />AUTHORIZATION TO RELEASE <br />"ANAL.YTIC:AL RESULTS <br />" GI O'I'13CHNICAL DATA <br />" 1fiViRONM1 N'I'Al.,/SI'1'I.: ASSI-SSMEN'I' IN1'OlZMA'I'ION <br />I, -€'Illi UN DF RS1GNED OWN I R AND/OR Oil I3RATOR 0€-1'€11: PROPERTY AND/OR FAC]LITY LOCATI?D AT <br />J4�..�._... �'-�' ° �``'._ c.5Z-t tt...._..._..................................._._....._...._ _...._...._.__... -.._. <br />(Stye", ilddress) (Citi,) <br />HE'REI3Y AOTHORIZL: <br />.......--__(Labo <br />story) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY I NVIRONMENI'AI., I-II ALTI-1 <br />DEPARTMENT AS SOON AS IT IS AVAILABLE: AND AT THE SAME TIME IT IS PROVIDED TO ME OR MY <br />REPRESENTA'T'IVE. <br />BUSINESS NAME: T' .Sv Ct., 1_v_ -,S -it' c--•+` (� I <br />(1/ Applicable) _ <br />OWNER:,,�€c o--`�`�`�,as L..- _Pn.tc r� �-t �. Com• <br />(11leccse Print) ('Title) <br />(Owner Signature) <br />?�/_q <br />(Duce) <br />ADDRESS: 1 LOO— <br />(il9ailing;)dc/rens) <br />- - - - ---- - - - —_ _ - - -... _.€.......... _.._.-------------- --- t - - - - -- - - - ... ` - <br />(Citi?) (Stale) ('Zip Code) <br />PHONE; («�Q µ)_•ms-�`"._ <br />EH 23 046 (Revised 07/21/10) <br />C-1 <br />