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-- ---- - ..,, 1 U 1tiGJGJ ICS ftJL r.{7t'{ <br /> SAN JOAQUIN COUNTY pUBLIC HEALTH SERVICES <br /> EWIROt`NIENTAL HEALTH DIVISION <br /> (204)468-3420 <br /> AUTHORIZATION TO RELEASE <br /> ' ANAL=CAL RESULTS <br /> " GEOTECHNICAL DATA <br /> ` ENVIRONMENTAL'SITE ASSr_SSI NT INFORMA7ON <br /> THE UNDIGNED OWNER AMD/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> JCAT ED AT l(v C, 1-441zq.,v;4 S <br /> (Screen Address) (Cry) <br /> aR EBY A UTHORM-7 S�QU/�A �N/�'�C Y 2 dr�I <br /> (Laboratory) <br /> RELEASE A";D ALL ANALYTICAL INFORMATION TO SAN IOAQUIN CO(JWTY PUBLIC <br />=ALT H SER CES-EN. VIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE Al*,1D AT THE SAME <br />-ME IT IS PRQVMFD TO ME OR MY REpRESEN'I'A=. <br /> sUSTNEs NAME: Ag o �`'I/A�i`'� / fir Cj S'•—cLA< <br /> (If App&uble) <br />)WN--� OP T09': 31ZZ /�IEjZC <br /> e ) aide) <br /> (let/Operator Sig�carrue) ej <br /> wailzng Add =) <br /> L 2t <br /> (ciry) (Stae) (Z1p Cade) _ <br /> 046 (Revis�d 10/19/98) page 9 <br /> I <br />