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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/OR OPERATOR OF THE <br /> PROPERTY AND/OR FACILITY <br /> LOCATED AT / X57. �.•✓1se.�.s� ).,���i�-�� <br /> (Street Address) (City) <br /> HEREBY /t _ -F� 5:n IL S <br /> AUTHORIZE(� <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: <br /> I Applicable) <br /> OWNER/OPERATOR: /J LOQ <br /> Please Print) (Title) <br /> ner/Operator Signature) (Date) <br /> ADDRESS: /D 4205C Soo /o <br /> ailing Address) <br /> /"Q So21 <br /> (City) (State) (Zip Code) <br /> PHONE:( S 9 ) � ' ' L I <br /> EH 23 046 (Revised 10/30/12) 8 <br />