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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> AUTHORIZATION TO RELEASE <br /> *ANALYTICAL RESULTS <br /> *GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/ IR�OPPE'R,�ATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATEDAT I W/0 N II `O� I( v,"C��, `'y) <br /> (StreetAddress) ,) (City) <br /> HEREAUTHORIZE EY\\4 nY\M-Vft SUbbnr- 1c,wnnlpw u MOW Lab <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: U G I I <br /> (If Applicable) <br /> W {� <br /> O <br /> NER/OPBRATOR: —)f SA— CM 1 U1 68 ty7 1 `;T" <br /> (Ple Print) (Title) <br /> (Owner/ rotor gndlure) ( at <br /> ADDRESS: I II 0 11Y1X`1/.YA H1U11(��t,Yn1J <br /> (Mailing Add ss) <br /> SAMA <br /> (City) /� (Stattee)/� (Zip Code) <br /> PHONE:(. Q—_2 )2 Q 1 Zl — ✓ -'v I J I��— <br /> EH 23 046 (Revised 10/30/12) 8 <br />