Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <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 7C,A-2 PACIFIC AVE r STOCr—Ttw t CA cl5207 + <br /> (Street riddress) (City) <br /> HEREBY -�p <br /> AUTHORIZE 'A'-SCJC tATG Q t. 0*XO 1ES' X906 tUA BCtt0LV 1 a r'R big a CA.qZ3 6� <br /> Alphq f�pl7f�ca1, c .�(q9; H'or^ <br /> /coq c�f Ste+ �� �Icrari+Ch�� C A -lq So.tZ 7 <br /> C/ <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESSENTATIVE. <br /> BUSINESS NAME: os CAL-t 4=06-N 1 A-- Q4S <br /> (If Applicable) <br /> OWNER/OPERATOR: C4�P-1& PAAjX11TmS CU fy�,cAk <br /> (Please Print) (Title) <br /> n8 02 0 <br /> (Owner/Operator Signature) (Date) <br /> ADDRESS: 131`f Trn AN i l` lid <br /> (Mailing Address) <br /> SETA--FP- SW4N s CA- CM70 <br /> (City) (State) (Zip Code) <br /> PHONE:( 5G2 3+0 <br /> EH 23 046 (Revised 11/21/06) 9 <br />