Laserfiche WebLink
SAN10 A Q U I N Environmental Health Department <br /> C0IJN I Y <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 LOCATED AT <br /> 4623 Da Vinci Drive Stockton , CA 95207 <br /> (Street Address) (Cit)) <br /> HEREBY AUTHORIZE <br /> Test American - 880 Riverside Parkway , Rancho Cordova , CA 95670 916 -861 -0400 <br /> (Laborator}) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE <br /> SAME TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE . <br /> BUSINESS NAME : 7- Eleven Inc . #20632 <br /> (If Applicable) (� 1 <br /> OWNER/OPERATOR: `� , ` �i `G �1�� QA V 1 <br /> (Please •int) (Title) <br /> (Owner/Operat ignature) (Date) <br /> ADDRESS : 7- Eleven Inc . P . O . Box 711 <br /> (Mailing Address) <br /> Dallas TX 75221 <br /> (City) (State) (Zip Code) <br /> PHONE : ( 972 828-6592 <br /> 8of10 <br />