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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209)468-3420 <br /> AUTHORIZATION TO RELEASE <br /> ti <br /> *ANALYTICAL RESULTS <br /> #GEOTECHNICAL DATA <br /> " ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 1-7100 SOutttt\ <br /> (Street Address) LL (City) <br /> HEREBY AUTHORIZE_ Ca re-Gh �i9a I V7tC�t�^• _ ' <br /> (Laboratory) <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: CGl open 4e r C n , <br /> Q(IfppWare— <br /> (Please <br /> licable)W <br /> OWNER/OPERATOR: Cr O� r e. <br /> (Please Print) (Title) <br /> (Owner/Operator Signature) ( te) <br /> ADDRESS: Q &-X 12 <br /> (Mailing Address) <br /> (City) (State) Op Code) j <br /> PHONE: ( 7) 47 <br /> i <br /> EH 23 046 (Revised 08113/99) Page 9 <br /> 6 <br />