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ENVIRONMENTAL AL HEAL H DEPARTMENT <br />SAN JOAQUIN COUN'T'Y <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <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 <br />Address) <br />HEREBY <br />(Laborntoty) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY <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 />iSwneClBUSINESSNAME: t �iIT �C i b�: LQg CLC.,.' <br />!! nre....t: ,J.ta1 <br />6 OPERATOR:4! � i r r V-{. 4ti%n n,.* r <br />(ntle) <br />(Ownerr//Op�e�raMtoryrSignature) <br />/� (Date) <br />ADDRESS: Q(_ i �_� _ 9 1. tiUa�(,C.��\VL•1+,• - <br />(City) - (State) (Zip Code) <br />PHONE: <br />EN 23 046 (Revised 12/31/07) 9 <br />