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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> i (209) 468-3420 <br /> AUT1101UMFION TO RELEASE <br /> i <br /> • ANAI.Y'1'ICAL RESULTS <br /> • OEO'I'ECIINICAL DATA <br /> • ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I1'llli UNDERSIGNED OWNER AND/OR OPERATOR OF TIIE PROP Y AND/OR A ITYe l <br /> LOCATED AT d <br /> (s ,1aa.esy ( ry <br /> IIrsRIillY AUTHORIZE <br /> (l aboraforr Ca sallant) <br /> 10 RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> IWALI'll SERVICES AS SOON {%S IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO <br /> I ' <br /> I ' <br /> ME OR MY REPRESENTATIVE. <br /> I <br /> ,I BUSINIiSS NAME : r z&/l/D/% cs)el7 s <br /> (V Apr iranlr) <br /> OWNER/OPERATOR : -Z ,�/�— Z41KIM <br /> (Please Print) fie) <br /> I <br /> I (Owner/Operator Signetnre <br /> ADDRESS: A lel <br /> (Afalllag Address) <br /> aw <br /> (C rye) t (slate) (zlrl <br /> PHONE: j ���- `57� <br /> DA'I F: <br /> Pogo B <br /> E14 23 041 (nedoed 7-10.02) <br />