Laserfiche WebLink
0 0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />AUTHORIZATION TO RELEASE <br />ANALYTICAL RESULTS <br />GEOTECHNICAL DATA <br />ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OR. OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT <br />(Street Aall (City) <br />HEREBY AUTHORIZE <br />(LaboraforY) <br />TO RELEASE ANY AND ALL ANALYTICALORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SOON AS IT IS AVAILABLE ND AT THE SAME <br />TIME IT IS PROVIDED TO ME OR MY REPRESEN TIVE. <br />51505m <br />(IfApplicable) <br />(Please Print) <br />(Owner Signature) (Date) <br />(Mailing Address) <br />WE <br />EH 23 046 (Revised 02/20/09) <br />zm�,• <br />