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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 /4 LA> --(!; /`AikS-rL - j AC RD <br />(Street Address) (City) <br />HEREBY AUTHORIZE <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: A Z --z P <br />(If Applicable) <br />OWNER: <br />(Please <br />(Title) <br />=►�Y <br />� ner Signature)) (Daae) <br />ADDRESS: 7,tt- U /kt <br />E <br />(Mailing Address) <br />7)2 k-r� y rA - 9 �� <br />PHONE: (46 ) ) '6 <br />EH 23 046 (Revised 02/20/09) <br />5 <br />(State) (Zip Code) <br />