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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />(209) 568-3420 <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 '415-J 5- F-KJMEa2 57-relT STDCKTZ) IV <br />(Sweet Address) <br />HEREBY AUTHORIZE M c C fes{ PBtu <br />(Laboratory or CansuUant) <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 />[Ou37D•7Ja:7_%to] <br />ADDRESS: <br />(If Applicable) <br />r? q W- SUSfi-N BU 2 ON) <br />Print) (Tide) <br />(Owner/Operator Signature) <br />6- 14, Nt erL <br />ME <br />(State) (Zip Code) <br />PHONE: (-2-0 ) -1 3 1 G <br />DATE: <br />EH 23 041 (Revised 7-10-92) Page 9 <br />