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obt 09 06 o9: 5Ga R R En*ering 818842376 P• 7 <br /> 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 PROPERTY AND/OR FACILITY <br /> LOCATED AT 470 t J LA P V1 S"C — <br /> (Street Address) (ul" <br /> HEREBYAUTHOE YN A ry ` u LLL <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: VA-1 e A r a <br /> 1 ' (If Applicable) <br /> OWNER/OPERATOR: ul+ 6tw nr -LA L <br /> (Please Print) (ni1e) <br /> O{�wner/Operator Signature) (Date) <br /> ADDRESS: {985 1A1 <br /> (Mailing Address) <br /> ug,,Ak 9 C A 3a�m <br /> (City) p 7 (State) (Zip Code) <br /> PHONE:( ) S t') 7 2�'SG <br /> EH 23 046 (Revised 8/9/06) 9 <br /> 7 <br />