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r. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (2W) 46&3420 <br /> AUTHORIZATION TO RELEASE <br /> • ANALYTICAL RESULTS <br /> • GEOTECHNICAL DATA <br /> ' ENVIRONMENTAQSITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 101 W. Charter Way, Stockton, CA <br /> (Street.4ddrral) (city) <br /> HEREBY AUTHORIZE Geo Analytical <br /> (Laboratory or Consultant) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE <br /> BUSINESS NAME: C IM11 TPi- W/4y -TIV lei -f f. C 61 , <br /> (IfA plicable) <br /> OWNER/OPERATOR: L)NA L S• xle i <br /> (Please Print)/ Al (Title) <br /> ��H,LZ.I�I � �/y✓�YYL <br /> (Owner/Operator Signature) <br /> ADDRESS: YJ 0 Y, 2 /3 <br /> (Mailing Address) <br /> 6'fj V <br /> (City) (State) (Zip Code) <br /> PHONE: ( 2 u `i ) S 7 6, — 751) <br /> DATE: <br /> 27 'D G <br /> EH 23 041 (Revised 7-10-92) Page 9 <br />