Laserfiche WebLink
09/26/2008 FRI 16:48 FAX 2094683433 SJC EHD <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />AUTHORIZATION TO RELEASE <br />* ANALYTICAL RESULTS <br />• GEOTECHNICAL DATA <br />* ENVIRONMENTAUSITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR THE PROPERTY AND/OR FACILITY <br />LOCATED AT <br />(Street Address) <br />HEREBY AUTHORIZE <br />0005/007 <br />(Laboratory) <br />TO RELEASE ANY AND AL)AN YTICAL INFORMATIONTO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENTAS SOON AVAILABLE AND AT THE SAME <br />TIME IT IS PROVIDED TO Y REPRESENTATIVE. <br />BUSINESS NAME: <br />(If Applicable) <br />OW NER/OPERATOR: <br />Print) (Title) <br />Signature) (Date) <br />ADDRESS: <br />(Mailing A(1dress) <br />PHONE: <br />Mom <br />w <br />EH 23 046 (Revised 8/3/07) <br />4 <br />(State) (Zip Cock <br />