Laserfiche WebLink
• <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209)468-3420 Fax: (209)468-3433 RPCEIVEI) <br /> AUTHORIZATION TO RELEASE MAR 18 2015 <br /> ENVIRONMENTAL. <br /> !4cA'-u ")c057r9c%.'T <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 LOCATED AT <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR MY <br /> —�- REPRESENTATIVE. <br /> BUSINESS NAME: C-4 1 ac C t,-- j <br /> (If Applicable) <br /> OWNER -3 u-�-L- bk W+' Q L� 'c,?AO s2 <br /> (Please Print) (Title) <br /> (Owner Signaturee))� (Date) <br /> � <br /> ADDRESS: _��( � (C� Jc� �} i�\ 1 (L <br /> ,q <br /> (Mailing Address) <br /> (City) (State) (Zip Code) <br /> PHONE:( �'c1 ) 9 3 !�3 0 0 <br /> EH 23 046 (Revised 07/17/14) <br /> 6 <br />