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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 /> • ENVIRONMENTALISM ASSESSMENT INFORMATION <br /> 1,THE UNL-113RSIGNED OWNER AND/OR. OPERATOR OF THE PROPERTY AND/OR FACII.-IlY <br /> LOCAThI) AT ,-,STQr/= o a (`� ��, n I �o v , c� ,� R-r �=r C��1�".}�.. .._.__— <br /> (SheetAddress) (ciw <br /> HEREBY AOTHORIZB- 7 gp� N1 uGC6M C� .�IFeDI�s W.- 12,M.�� �. .._, <br /> (Lal orarmy or Consulratu) <br /> TO REI,EASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNPIt <br /> TY $I f <br /> HEALTH Sl-,R VICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME ff IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINVSSNAME: <br /> (IfApplicable) <br /> OWNEWOPERATOR: �1, , <br /> (Please Mile) <br /> ,-Z�, <br /> (OwneNOpero[o ipna[ure) \\ <br /> ADDRESS: I4=-7S C l 1 � yc� y �l� L a (ItN <br /> (Mailing Address) l <br /> Acr a onas\11 o C <br /> (Ciry) Male) (Zip Cute) <br /> PHONE: H( ) O 1 ti B4 o I _---.---- <br /> DAT(-:: z�/ ) / 9 QI <br /> EH 23 0-11 (',iscQ 740-92) Pagc 9 <br />