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• • <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 /> 1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT Z 5-o0 L (_ n cl; <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE _S <br /> (Laboratory) <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 NAME: U-5A �145C1 c Ej� <br /> (If Applicable) <br /> OWNER/OPERATOR: 3 FjASE�I iAJ� <br /> (Please Print) (tide) <br /> (Owner/Operator Signature) (Date) <br /> ADDRESS: 1 '2_(,,( G7 , ('-Q— ,ST-, <br /> (Mailing Address) y <br /> eQA4, kjb, l�Q W -2 (o <br /> (City) (state) (Zip Code) <br /> q <br /> PHONE: ( `D° <br /> F11 23 0.16 (Revised 9/11/96) Page 9 <br />