Laserfiche WebLink
v <br /> 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 OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT �1 S� FPe"t.0t1t O Cl<. C 9571D5 <br /> s <br /> HEREBY AUTHORIZE L1.1(Street e&"a , �L u C1 <br /> ( ry or GAsultanl) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN CO 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: �.e�l i.0►1. � n O� �- <br /> (If Applicable) <br /> OWNER/OPERATOR: U� �aL�.tAfL <br /> CIO U,F� 112 2L+ P--'u �-- <br /> (Please Print) (Title) <br /> (Owner/Op ` or ignaturej� <br /> ADDRESS: `5 "15 w '�5 CU7 St <br /> (Mailing Address) <br /> 4avkm-n C74,- <br /> (City) (State) (Zip Code) <br /> PHONE: (—i ) 3 44 <br /> DATE: L 1 I rl 1 cm A <br /> EH 23 041 (Revised 7-10-92) Page 9 <br />