Laserfiche WebLink
i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209)468-3420 <br /> AUTHORIZATION TO REL ASE <br /> • ANALYTICAL RESULTS <br /> + OVIOTECHNICAL DATA <br /> + ENVIRONMENTAIArM ASSESSMENT INFORMATION <br /> 1, THE UNDERSIGNED OWNER AND/OR OPWkATQR QF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT c - - <br /> (Saer � (cam) <br /> HEREBY AUTHORIZE — - <br /> L4bwvfwy or Cori u Wnt) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES AS SOON AS IT IS AV"LE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: — 14/i'/�tll <br /> (If Applicabk) <br /> OWNER/OPERATOR: �F. : • �!/7N/</C7 � �J 4f l�1�� - <br /> . ( lcasa Pant) _ �/ ?lrle) 7r <br /> - (Owner per�tor Si�uattN :•�-' ..._.:.__.._..._.._ <br />{ ADDRESS: d 1 <br /> - (Matllag Address) <br /> (sy) (SOW (Zip Cade) <br /> PHONE: (20 9, <br /> r <br /> DATE: /� l <br /> Ell 23 041 (Revised 7-10-92) Page 9 <br />