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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 <br /> AUTHORIZATION TO RELEASE <br /> *ANALYTICAL RESULTS <br /> *GEOTECHNICAL DATA <br /> " ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIG'NJE OWNE AND/OR OPERATOR OF THE PR'OP`ERTY AND/OR FACILITY <br /> LOCATED AT A ( �4 A,�A � �T X'f� W 14 <br /> 1_ � NOL®b <br /> ((Street Address) (City) <br /> HEREBY AUTHORIZE <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: 4 G" <br /> (If Applicable) <br /> OWNER/OPERATOR: <br /> (PleasePrint) (Title) <br /> (Owner/Operator Signature) (Da ) <br /> ,4 -cT <br /> ADDRESS: 7 ���__ O KJ <br /> (Mailing Address) <br /> Qs w tJ r& 2� <br /> (City) �( (State) (Zip Code) <br /> PHONE:(m <br /> EH 23 046 (Revised 8/3/07) <br /> 4 <br />