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SAN JOAQUIN COUNTY PUBLIC HEALTH RVICES <br />ENVIRONMENTAL HEALTH DIVIS,,4 <br />(209) 468-3420 <br />AUTHORIZATION TO RELEASE <br />• ANALYTICAL RESULTS <br />• GEOTECHNICAL DATA <br />• ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />L THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT L r l,Lc Sic /t <br />HEREBY AUTHORIZE rl 'i yy l c r<, i ! G't <br />V (Labo+afoq or Comuft t) <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 Ipplicable) <br />OWNER/OPERATOR-- <br />ADDRESS: <br />WNER/OPERATOR: <br />DATE: <br />ADDRESS: _ Y L: / <br />(Adaiting <br />A& *q) <br />(city) <br />PHONE c` �( <br />e <br />EH 23 041 (Revised 7-10-92) Page 1 2 <br />144 (z <br />�1503� <br />(State) (Z4p <br />