Laserfiche WebLink
FEB-12-1996 07:32 P.07 <br /> OL/15/2006 TUB 14:52 BAR Z0946e 3433 STC axo 2006/008 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephoael (209)468-3420 Fax:(209)468-3433 <br /> AUTHORIZATION TO RELEASE <br /> •ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> • ENVIRONMENTAL/SITEASSESSMENTINFORMATION <br /> I.THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT <br /> (Siwet Add0w) (City) <br /> HEREBY AUTHORIZE <br /> (LaboraNry) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN IOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAAB <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSMESS NAME: <br /> (ifAppliooble) <br /> OWNERIOPERATOR: <br /> (pl4ale print) miw <br /> (Dmror/OpaaatorSignatnre) (nate) <br /> ADDRESS: <br /> (MallingAddrw) <br /> (City) (Start) (Zip rode) <br /> PHONE:( I <br /> EH 23 046 (Rcvlacd 8/3107) <br /> 4 <br /> C00�j XVA Tb:OZ GOOF/ST/SO <br />