Laserfiche WebLink
U'J/V1/2UkJ4 1b'23 2094603433 FIFTH FLOOR PAGE ut <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> (204)468-3420 <br /> AUTHORIZATION TO RELEASE <br /> *ANALYTICAL.RESULTS <br /> "GEOTECHNICAL.DATA <br /> " ENVIRONMENTAUSITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OFERATOR OF THE PROPERTY ANDJOR FACILITY <br /> LOCATED AT <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> (Laboratory) <br /> TO RELEASE ANY AND ALT.ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY I;NVIROi�'MkNTAL 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 /> (IfApplicable) <br /> O WNERIOPERATOR: <br /> (Please Prinr) (Title) <br /> (Owner/Operator Signature) (Date) <br /> ADDRESS: <br /> (Mailing Address) <br /> (City) (State) (Zip Code) <br /> PHONE_ <br /> EH 23 046 (Revised 1/24/02) <br /> 6 <br />