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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3410 <br /> AUTHORIZATION TO RELEASE <br /> • ANALYTICAL RESULTS <br /> • GEOTECHNICAL DATA <br /> • ENVIRONMENTAUSITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 225 S. Crescent Avenue, Lodi , CA 95240 <br /> /1(�'reetAddress) �, <br /> HEREBY AUTHORIZE L?c�� Xc 4 / r <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: <br /> (If Applicable) <br /> OWNER/OPERATOR: A,,4z 0 P LI'20,e I1i�AJ <br /> (PI Print) <br /> (Owner/Operator Signature) <br /> &7- + , <br /> ADDRESS: �3�6,5 /` /T��-zT G,J G G n ' <br /> (Mailing Address) <br /> an/t,,ce,,eo <br /> (City) (Stare) (Zip Code) <br /> PHONE: <br /> DATE: - -c/ y <br /> EH 23 041 (Revised 7-10-92) Page 9 <br />