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1, THE UNDERSIGNED <br />LOCATED AT <br />(Street <br />HEREBY <br />AUTHOR <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />AUTHORIZATION TO RELEASE <br />* ANALYTICAL. RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAUSITE ASSESSMENT INFORMATION <br />AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />(Laboratory) <br />(City) <br />TQ RELEASE. ANY AND A.I.I. ANALYTICAL INFORMATION TO SAN JOAQUIN CO NTY <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 />0w+le,�USINF'SS NAME: <br />,WAQ4 /OPERATOR: <br />(If Applicable) <br />eCi. +v e" <br />(Please P j <br />L C, <br />e,),tr <br />(Owner/Operator Signature) (Date) <br />ADDRESS: <br />/Mni7ino edd..rv..i <br />(City) 1 (State) (Zip Code) <br />PHONE: (d <br />Ell 23 046 (Revised 12/31/07) 9 <br />