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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 UNDERSIGNhhE��D OWNER <br /> /AND/OR <br /> `OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT ay� S, ►//vVl/mac �9 <br /> (StreetCC7) vac. (C(c4)HEREBY AUTHORIZE l-,� <br /> � <br /> (Labordtory or Consultant) <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: Z >`,rrrv�A.�/4z %J <br /> (If Applicable) <br /> OWNER/OPERATOR: Jc:- � J�UC cry�n C-,n,- A-� <br /> (Please Print) (Tale) <br /> p <br /> (O�w/ner/ rator Signature) <br /> ?iCi7i r-_ <br /> ADDRESS: W C— <br /> (M1ailing Address) n <br /> (City) (State) (Z)q Code) <br /> PHONE: (zt'l ) LA(0�p <br /> DATE: <br /> EH 23 041 (Revised 7-10-92) Page 9 <br />