Laserfiche WebLink
SAN JiJ QVfN COUNTY <br /> ENVIRONMENTALH HEALTH DEPARTMENT <br /> 9 <br /> AUT144RIZATION TO }RELEASE <br /> "ANALYTICAL RESULTS <br /> *GEOTECUMCAL DATA <br /> ENVIRONMENTAL JSTTE ASSESSMENT INFORMATION <br /> I,THE UNDEPLSIGNED OWNER AND/CSR OPERATOR OF THE PROPERTY ANDIOR FACILITY <br /> LOCATED AT i ; ) <br /> J i (Citi') <br /> (Sireet Address) <br /> HEREBY AUTHORIZE <br /> (Labnratary) <br /> TO <br /> 7t�'i.FA,SE ANy AND ALL ANALYTICAL INFORMATION TO SAN JOAQ�7 COUNTY ENVIRONMENT1tEALT14 <br /> DEPARTMENT AS SOON AS If IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: <br /> (If ripplicable) <br /> OWNEWOPERA OR: �( <br /> lease Print) mile) <br /> (Qwiner/Oper$t'Signature) (Date) <br /> ADDx ss: �Uc ✓ ( Y-� &—t <br /> (Mailing Addre,$) <br /> (City) (State) (zip Code) <br /> ETI 23 046 (Revised 1/24/02) <br /> b <br /> JA �nHH <br /> HI-IV--IH 1HIN-4*- NTAN; RPTAtgV 8T.:9T 90AZ/EZ/Eta <br />