Laserfiche WebLink
11t U"1! LUU•f U7• JL <br />LV 7YOOJ�iJJ <br />• <br />r it IN r LL"JK HAUL bid <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />(209) 468-3420 <br />AUTHOMZATXON TO RELEASE <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* <br />ENVIRONMENTALISM ASSESSMENT INFORMATION <br />L THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT 12— <br />(Street <br />- <br />(Street Address) <br />HEREBY AUTHORIZE <br />(Laboratory) <br />(City) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br />TIMIr IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: <br />(lfApplicable) <br />OWNER/OPERATOR; <br />ADDRESS: <br />q(i jI >I z <br />(Please Print) <br />(Mailing Address) <br />c1 ` I <br />////-//0 <br />(Date) <br />(city) (State) (Z,p Code) <br />PHONE (Z� ) , <br />EH 23 046 (Revised 1124/02) <br />