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 <br /> OWNER AND/OR/ OPERATOR OF THE PROPERTY AND/OR FACCILITY�/ <br /> LOCATED AT � I SCgTA ilS,00 WA -0) 1n <br /> (Street Address) (city) <br /> HEREBY AUTHORIZE M G CA to /I Q/16lw;o <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: I oT) 1 I I I IV e s+41i O i <br /> (If A plicable) ' <br /> OWNER/OPERATOR: EA t�_ /l A i c i'T q)W N <br /> (Ple y- ' t) ��j /�j (Title) <br /> (/; 02— 7--1— <br /> (Owner/Operator Signature) (Date) <br /> ADDRESS: /01 SO \)off WI Isom Wa <br /> (Mailing Address) <br /> ST.0 c C- q 5c p <br /> (City) (Stare) (Zip Code) <br /> PHONE: (-30_) — 0 � k <br /> EH 23 046 (Revised 9/11/96) Page 9 <br />