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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 -5-7-4 t,,> <br />d AA-6S-rIlr 1 A0 E <br />(StreetAddress) (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: <br />OWNER: e--% <br />(If A) <br />(Please Print) <br />(Title) <br />L <br />=� —( C) <br />,._—_(ner Signature) (Date) ` <br />ADDRESS: -T.- tc�i { 5;�2 Lll\t E <br />(Mailing Address) <br />l �y CA <br />(City (State) (Zip Code) <br />PHONE: (;-6 3 ) ' -R A (.K <br />EH 23 046 (Revised 02/20/09) <br />5 <br />