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4 <br />SAN JOA.QUIN 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/0R OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT <br />1553 Colony Rd Moon <br />(Sh•eet Address) (City) <br />HEREBY AUTRORIZE <br />Cq c l fa rms C,4&fL,97—,a fFRL/1c F �(1 t ,4 �,t- bo <br />story) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN 70AQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPAR I%4ENT AS SOON AS IT TS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR MY <br />REPRESEN'i'ATTVB. <br />BUSINESS NAME: Love's Travel Slop 4223 __....__ <br />((f/Jpplicable) <br />OWNER: Kevin Nickell for Love's Travel Stops of California Environmental Divisions Manager _ <br />(Please Print) (Title) <br />03/12/14 <br />(Owner Signature) (Date) <br />ADDRESS: PO Box 26210 <br />(MallingAddress) <br />Oklahoma Ciry OK 73126 <br />(City) (State) (Zip Code) <br />PHONE: C 40L_) 242-2455 <br />BE23 046 (Revised 07/21/10) <br />RECEIVED <br />APR 21 2014 <br />ENVIRONMENTAL HEALTH <br />DEPARTMENT <br />