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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 />* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY/AND/OR FACILITY <br />LOCATED AT 5��1� /�' s7—' L'� e;;�_70 <br />(Street Address) (City) <br />HEREBY AUTHORIZE S <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br />HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: <br />(IJ Applicable) <br />OWNER/OPERATOR: <br />Signature) <br />CEJ / <br />(Mailing Address) <br />41axl: � Z�? <br />(City) (Su <br />PHONE: ( 2tF ) SJ'` J `,2 7 <br />EH 23 046 (Revised 9/11/96) Page 9 <br />r1S3� <br />(Zip Code) . <br />