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DWIRONMENTAL HEALTH DEPA & EL) <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209)468-3420 Fax: (209)468-3433 MAR 10 2016 <br /> AUTHORIZATION TO RELEASE ENVIRONMENTAL <br /> 4-IFQI�IJ tZCDBIaT�,��A1T <br /> *ANALYTICAL RESULTS <br /> *GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF/THE PROPERTY A/N�D,/OR FACILITY <br /> LOCATED AT /O 6.J� WZ� ����� �� <br /> (S'treet Address) (CIty) <br /> AUTHORIZE 6�S& <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: ®L/? <br /> (If Applicable) dig <br /> OWNER/OPERATOR: G�b <br /> (Please Print) (Title) <br /> 0 (/ <br /> (Owner/ perator Signature) (Dak) <br /> ADDRESS: /?a 43 Qx�9 3 <br /> (Mailing Address) <br /> G p> / (�W. <br /> (City) / (State) (Zip Code) <br /> PHONE: d O ��f — / �/y <br /> ru')'l ndA (D—,;vaA 11/10/1011%1 4 <br />