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 /> ENVIRONMENTAUSITE ASSESSMENT INFORMATION <br /> 1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> 2• <br /> LOCATED AT D'SCD IZA56W Ro. I-OACq C.• 'r• mp <br /> (Strew Address) �/� (City) �— <br /> HEREBY AUTHORIZE X Yh IN 0/Y -) <br /> (Laborwary) <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: J&UdL Cd? WIZ <br /> (if Applicable) <br /> nn •-------• <br /> OWNER/OPERATOR: AVS/ 1,11L<-6x&,j /,/r`/-toeirrs�vj 0% CO/1c;cj7U.•.+S <br /> (Please Pnnt) (Title) <br /> ha L G✓,ccv. / 3iZ,3 Fk <br /> (Owner/Operator Signature) (Date) <br /> ADDRESS: a YM ) ✓ASSo, ) V a. <br /> (Mailing Address) <br /> l Clike-� CA <br /> (City) (State) (Zip Cade) <br /> PHONE: (Al ) ! 35-- Y/Y/ (=Y Yajv <br /> EH 23 046 (Revised 9/11/96) Page 9 <br />