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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 IORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF/�HE PROPERTY AND/OR FACILITY <br /> LOCATED ATANoheast corner of Farmington Road/and E Mariposa Rd Stockton, CA <br /> eet Address) (Cita')HERESY Sbs <br /> AUTHORIZE <br /> (Labor tory) <br /> TO RELEASE ANY ANDL ANALYTICA INFORMATION TO SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH PARTMENT SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME O MY REPRE ENTATIVE, <br /> BUSINESS NAME: PSI <br /> (If Applic <br /> OWNER/OPERATOR: Fr Department Manager <br /> (Plea <br /> in - (Title) <br /> z (z) f I <br /> (Own erator Signature) (Date) <br /> ADDRESS: 4703 Tidew ter Avenue, Suite B <br /> (Mai ng Address) <br /> Oakl nd CA 94601 <br /> 'Cit}'') (State) (Zip Code) <br /> PHONE: 510 �434-9200 <br /> EH 23 046 (Revised 8/1/11) 8 <br />