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 />• ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT <br />HEREBY AUTHORIZE <br />i <br />(City) <br />(Iabantay or Consnitat)1) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br />HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br />TO ME OR MY REPRESENTATIVE <br />BUSINESS NAME: <br />(If App6cabk) <br />OWNER/OPERATOR: M%3RIC A 0 /VC91y% V, e, d !� &V <br />(Please Print) / (7itk) <br />Signature) <br />ADDRESS: g00 w,-& C rcA S �/2e <br />(Mailing Address) <br />,�, cp 9s.2o3 <br />(State) (zip Code) <br />PHONE: ( ao C( , -"lti C^ - s 2 s 1 <br />DATE: U I a S I q-3 <br />EH 23 041 (Revised 7-10-92) Page 9 <br />