Laserfiche WebLink
10/25/2002 10:36 2094683433 FIFTH FLOOR PAGE 06 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> (209)468-3420 <br /> AUTHORIZATION TO RELEASE <br /> •ANALYTICAL RESULTS <br /> •GEOTECHNICAL DATA <br /> * ENVIRONMENTAUSITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACIIxry <br /> LOCATED AT ' <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE v--' <br /> e f-t ��- e c) z ti\ V ! � c 7�7 � v( 1' ot-� [C S e S <br /> T <br /> (Laboratory) <br /> C' ct 1 / z r_ A. �L\ <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQuiN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> Co 7 <br /> BUSINESS NAME- T (f C-1 c- C C I S <br /> (If Applicable) <br /> OWNER/OPERATOR: <br /> C v c i< 1) 0 L4.) <br /> (Please Print) (Title) <br /> _ p Z <br /> (Owner/O r or signature) (Date) <br /> ADDRESS: �_,7 (-— 3 <br /> (Mailing Addres <br /> (City) (State) (Zip Code) <br /> PHONE: O Cy / _ C c FS <br /> EH 23 046 (Revised 1tM4/02) <br /> 6 <br />