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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 />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT y� 3 60 U&BOA S r._ s%d ae %'0-) 1 �- <br />,LStre t Address) (City) <br />HEREBY AUTHORIZE 1C 7 �'4111LPO,60�1 O <br />(Laboratory or ConsuUant) <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 />OWNER/OPERATOR: <br />(If Applicable) <br />NSO� - /i4 /L/Ty Cj4•.Ijtre <br />(Please Print) y ` , — (Title) ' <br />�k C%/ IPSGC J tI ✓„^"'�' <br />ADDRESS: -Po 190A 1!;-6 3 <br />(Mailing Address) <br />(City) q �7a--� / t� (State) (Zip Code) <br />PHONE: ( 91�p / / 1 K <br />DATE: <br />EH 23 041 (Revised 7-10-92) Page 9 <br />