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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3420 <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 4807 AIRPORT WAY STOCKTON <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE FGL ENVIRONMENTAL LAB, STOCKTON, CA <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 AVAII.ABLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: CUSTOM RV <br /> (If APP&abu) <br /> OWNERIOPERATOR: ART KOROCK <br /> (Pleasefie Prinntt)J// / (Tule) <br /> (Owner/Ope for Signature) <br /> ADDRESS: 4807 S. AIRPORT WAY <br /> (Mailing Address) <br /> STOCKTON, CA 95206 <br /> (city) (State) (Zip Code) <br /> PHONE: (209 982-5723 <br /> DATE: <br /> EH 23 041 (Revised 7-10-92) Page 9 <br />