Laserfiche WebLink
• • <br /> SA A'�I O n O I )I � Environmental Health Department <br /> ---/-.-�-'C\0 U NH lT,f YU <br /> AUTHORIZATION TO RELEASE <br /> * ANALYTICAL RESULTS <br /> a <br /> * GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> 1,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT <br /> (Street Address) (City) <br /> 1 HEREBY AUTHORIZE <br /> (Labor tory) <br /> TO RELEASE ANY A L A ALYT AL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT S SOO S IT S AVAILXBLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR <br /> MY RYPRESENTATIVE. <br /> USINESS NAME: <br /> ( Applicable) <br /> OWNER: <br /> (Please Print) (Title) <br /> (Owner Signature) (Date) <br /> ADDRESS: <br /> (Mailing Address) <br /> (City) (State) (Zip Code) <br /> PHONE: <br /> 6 of 6 <br />