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u <br />..00 <br />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 OWN,/ER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT _ YT/6- <br />(Street Address) (City) <br />HEREBY AUTHORIZE L zt) <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 NAYtE: <br />(if Applicable) <br />OWNER/OPERATOR: Z J )} A] U D <br />(late) <br />/ - - <br />ADDRESS: V-5 15 N Ci m t�r � <br />S-f6LO�-Pon/ <br />(State) (Lip Code) <br />PHONE:( d 0"?) / 3) — LD % y 9 <br />EH 23 046 (Revised 10/19/98) Page 9 <br />