Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DMSION <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 J 72�� L,I�EST Z-acf<FUt2rJ 4&r,;P I <br />(Street Address) (City) <br />HEREBY AUTHORIZE ,-:: �; - .: 5 0.,4 2G G/1 / <br />(Laboratory 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 <br />TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: <br />(If <br />OWNER/OPERATOR: <br />(Please Print) /) (Title) <br />/4 1 /I <br />(Owner/Operator <br />ADDRESS: ( Z Z S L.C�C t� i tC (�—cJ✓c t� <br />(Mailing Address) <br />PHONE: <br />DATE: <br />l-00 1 (2 6 <br />(City) (State) (Zip Code) <br />EH 23 041 (Revised 7-10-92) Page 9 <br />