Laserfiche WebLink
PUBLItPHEALTH SERICES U IN:..�o <br /> SAN JOAQUIN COUNTY Q` N <br /> JOGI KHANNA NKI),KP.H. <br /> Health Officer _ <br /> P.O. Box 2009 ® (1601 East Hazelton Avenue) • Stockton, California 95201 <br /> C44%Fp'Ra`4 <br /> (209) 468-3400 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3427 <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 <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> (Laboratory or Consultant) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMMATION 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 Applicable) <br /> O WNER/OPERATOR: <br /> (Please Print) (Tule) <br /> (Signature) <br /> ADDRESS: <br /> (Mailing Address) <br /> (City) (state) (zip code) <br /> PHONE: ( ) <br /> DATE: <br /> E?i 23 041 (REV 2/8/91) wp Pa;e 9 <br /> A Division of San Joaquin County Hcalth Care Service <br />