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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 46&3410 <br /> AUTHORIZATION TO RELEASE <br /> • ANALYTICAL RESULTS <br /> • GEOTECHNICAL DATA <br /> • ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 25474 F_ Hwy 4. Farmineton. CA 95230 <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE Del-Tech <br /> (Laboratory or Con=k") <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: —Farmington Fire De,F,1„ <br /> (If Applicable) I <br /> OWNER/OPERATOR: Cd, <br /> ea Print) (Title) <br /> (Owner/Operator Signature) <br /> ADDRESS: 25474 E. Hwy 4, Farmington, CA 95230 <br /> (Mailing Address) <br /> j(City) PG (State) (Zip Code) <br /> PHONE: ( d�I) <br /> DATE: <br /> EH 23 041 (Revised 7-10-92) Page 9 <br />