Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />* ANALYTICAL RESULTS <br />* ENVIRONMENTAL/Sm ASSESSMENT INFORMATION <br />1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE ]PROPERTY AND/OR FACILITY <br />LOCATED AT <br />le /,? W ' I�A411YZ4 ZA-,VE 0 <br />(Street Address) (cftv) <br />S <br />(Labommy) <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 <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: <br />(y <br />(Pleas Print) (Title) <br />(Owner Signature) (Date) <br />ADDRESS: PJ - e(Date) <br />Ive- <br />(Mailing Address) <br />(City) (State) (Zip Code) <br />L <br />PHONE: C�? �Pf 1 9 -0 - 7 70 d <br />EH 23 W (Revised 02/20/09) <br />5 <br />