Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />(209) 468-3420 <br />AUTHORIZATION TO RELEASE <br />* ANALYTIC.AL RESULTS <br />GEOTECHNICAL DATA <br />ENVIRONMENTAL SITE ASSESSMENT INFORMATION <br />I. THE UNDERSIG\TED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />J. <br />LOCATED AT 19 ,C� . (!&- • 9'S33L� <br />(Stet Aaaress) (City) <br />HEREBY AUTHORIZE 1_ <br />(Lahorato7) <br />TO BELE ASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br />HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SANIE <br />IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME. <br />(If Aicaolef !' <br />OWNERJOPERATOR: Jy �' I.. Q O �[ <br />(Please Print) /) A <br />ADDRESS: 4&s- E C <br />Signature) , <br />. ule) <br />(Date) <br />(Mailing Address) U <br />.d Ck • 95,-07 <br />(City) 1 (State) (Zip Code) <br />PHONE: (J-0 1 ) 343 —AD l) / 02® 9 " 4 77 " 34,,q3 <br />EH 23 046 (Revised 9/11196) Page 9 <br />