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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DMSION <br />(209) 468-3420 <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 />J <br />LOCATED AT 7 _%L_ v-3 ,z, Q <br />(Street Address) (City') <br />HEREBYAUTHORIZE _-n4NjAL\/T'1GA1 14-o5_ !C �3�: S_ A M���=Crr, L;A <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br />HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE_ <br />BUSINESS NAME: `=7�"t - �,-; C /%Li <br />(If Applicable) <br />OWNER/OPERATOR: SA"% ti"A-P] <br />(Please Print) <br />ADDRESS: `J 7Y-^ �L/ <br />(Mailing Address) <br />_AL e -y0 4 - <br />(City) i(State) <br />c <br />PHONE: (Za I ) 933 "— 3 `fI� <br />EH 23 046 (Revised 10/19/98) Page 9 <br />(Title) <br />jz s . ?y <br />(Date) <br />S-3 7� <br />(Zip Code) <br />