Laserfiche WebLink
SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209)468-3420 <br /> AUTHORIZATION TO RELEASE <br /> * ANALYTICAL RESULTS <br /> * GEOTECHNICAL DATA <br /> * ENVIRONMENTALSITE ASSESSMENT INFORMATION <br /> I. THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT <br /> HEREBY AUTHORIZE (Street Address) (City) <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: C l ©/_ Il(cof c Gz D. . S. <br /> �yJ(If Applicable) - n <br /> 1�/®/�f/�L7 C�9TlV�� 7\ b5eciP <br /> OWNER/OPERATOR: Q <br /> (Please Print) (15tte) <br /> c,:1V_y . q ^q�v� 3 / � � 06 <br /> (Owner/Operator Signature) (Dare) <br /> ADDRESS: p�Q �� � L� ly. <br /> (Mailing Address) <br /> % 16 <br /> (City) '/ (State) (Zap Code) <br /> PHONE: ( 3 .Z ! ` <br /> EH 23 046 (Revised 10/19/98) Page 9 <br />