Laserfiche WebLink
' <br /> SAN JOAQUIN COUNTY PUBLIC HEALA-I SERVICES <br /> i ENVIRONMENTAL HEALTH DIVISION <br /> a <br /> (209) 469.3420 <br /> AUTHORIZATION TO RELEASE <br /> �z <br /> • ANALYTICAL RESULTS k <br /> .0 <br /> • GEOTECHNICAL DATA <br /> • ENVIRONMENTALJSITE ASSESSMENT INFORMATION <br /> i� <br /> 4 <br /> 1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT <br /> 900!2 E. Victor Road, Lodi , CA 95240 <br /> (Street Address) 'i (City) <br /> { HEREBY AUTHORIZE Jrt / r, �,' A-) GeoAna] tical. Laboratories <br /> (Laboratory or resultant) <br /> # TO RELEASE ANY AND ALL ANALYTICAL INFORMATIOMTO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: t/ ' f „ " <br /> ii (If Applicable) <br /> OWNER/OPERATOR: IL CtiG Ftp <br /> i, <br /> (Please t ,(Tule)' <br /> (Owner/O ra r Signature) <br /> r7 k <br /> ADDRESS: <br /> i (Mailing Address) <br /> i <br /> (City) (State) (Zip Code) <br /> PHONE: { � <br /> { DATE: <br /> i <br /> EH 23 041 (Revised 7-10-92) Page 9 <br /> f <br /> i <br />