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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />(709) 468-3420 <br />AUTHORIZATION TO RELEASE <br />ANALYTICAL RESULTS <br />. GEOTECHNICAL DATA <br />. ENVIRONMENTALISITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT ) 3C VI <br />(Street Address) / (City) <br />HEREBY AUTHORIZE <br />(Laboratory or Consultant) <br />TO RFI—RASE 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 />(Please Print) <br />Signature) <br />ADDRESS: i Z7, e w4er— <br />(Mailing Address) <br />(City) // / r (state) (Zip Code) <br />� <br />PHONE: ' 1-l6e 7Gi <br />DATE: <br />EH 23 041 (Revised 7-10-92) Page 9 <br />