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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 49PERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATEDAT 2 ,1 -- ujE57- l( K SiRcET CSrOEWALk IIL LTJ <br /> (Strew Address) (CuY) <br /> HEREBY AUTHORIZE G K�/ 1=N✓L20'U M EAIIr9 L 01Z SoR k f E2 TcCHnlor <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: THE G.L Ty of t-wLy .. <br /> (IfAPplicable) <br /> OWNER/OPERATOR: /'1Q PAL) 1IFeMA <br /> (Please Print) (Tule) <br /> (Owner/Operator S-lpature) 1a7 2-1 <br /> ADDRESS: SZD TQ6cl /3LOD <br /> (Mailing Address) <br /> TeA(,�� G4 c, 376 <br /> (CiW (Stare) (Zip Code) <br /> PHONE: ce 6 — t.I LIZ 0 <br /> DATE-- <br /> (0 <br /> ATE (o lZ I ICI <br /> EH 23 041 (Revised 7-10-92) Page 9 <br />