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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 OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT ' 01A <br />(Street Address) (City) <br />HEREBY AUTHORIZE <br />gsu9 <br />(Laboratory) <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 />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: w c�, SA-uy� *-7-7,69 <br />(IfApplicable) <br />OWNER/OPERATOR: <br />h1e 1 f -t 1.. ICk50ti Ick c1 <br />(Please Print)(title) <br />11 Q (Owner/Operator Signature) (Date) <br />ADDRESS: aH IID -1 Aholoa q `Urtj <br />(Mailing Address) <br />t:I�ir TL (00-Lq <br />(City) (State) (Zip Code) <br />PHONE: (�y�7 ) 6$8 c-17 (o <br />EH 23 046 (Revised 8/3/07) <br />4 <br />