Laserfiche WebLink
s <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> (209)468-3420 <br /> AUTHORIZATION TO RELEASE <br /> *ANALYTICAL RESULTS <br /> *GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMI.N <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND14R FACILITY <br /> LOCATED AT <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATI TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT HE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENT IVE. <br /> BUSINESS NAME: <br /> (If Applic ble) <br /> OWNER/OPERATOR: <br /> (Pleas Print) (Title) <br /> weer/Operator Signature) (Date) <br /> ADDRESS: <br /> (Mailing Address) <br /> (City) (State) (Zip Code) <br /> z— <br /> PHONE: ) <br /> EH 23 046 (Revised 1/24/02) <br /> 6 <br />