Laserfiche WebLink
ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNT' <br />Telephone: (209) 468-3420 Fax: (209) 4683433 <br />AUTHORIZATION TO RELEASE <br />* ANALYTICAL RESULTS <br />"GBOTECHNICAL DATA <br />* ENVIRONMENTALlSITE ASSESSMENT INFORMATION <br />I, T14E UNDERSIGNED OTNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT <br />(Street Address) tCFty) <br />TC/4 HEREBY AUTHORIZE <br />(Laborntory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN 10AQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SOON AS 1T IS AVAILABLE AND AT THE SAME TIME IT iS PROVIDED TO ME OR MY <br />fREPRESENTATIVE. /f <br />BUSINESS NAME: / � � / v S 166 /VQ, l q /Q <br />7( <br />Ard nnlfnnl.lei <br />7- 4r -l- ezl <br />ADDRESS: WC- <br />` (Mailing <br />PQ �3 cx -711 ,U4u--A-s- <br />(Ttlej �"-�' G/1Gvs <br />December 18, 2015 <br />(Date) <br />- - -rX 7,54?z1 <br />�j (city) (State) (Zip Code) <br />PHONE: (� �ZV _ <br />EH 23 046 (Reviser! 07117/14) <br />