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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 PROPERTYAND/OR FACILITY LOCATED AT <br /> Shtk, lkr of 9 c,"A 4 S Zl1r <br /> (Stree Ams) (City) <br /> HEREBY AUTHORIZE <br /> P J?�E � YA21-e uw. S�Y0 <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR MY <br /> � <br /> , REPRESENTATIVE.. <br /> p1 <br /> BUSINESS NAME: N A-i-ep A-11A ./r <br /> (IfApplicabpple) <br /> OWNER: a)gi`� <br /> (Please Pr t) (Title) <br /> ^mer Signature) I(Dake) <br /> ADDRESS: U Sl-A)e, Q A -/ <br /> (Ma ing A ss) <br /> D�io" <br /> p q c (City) a (State) py(rZ,ip Code) �} <br /> PHONE:(�� �J P 6 - Z l 1 >0 OY r-J— Lf D 0 - 0 n 9/ t4CI <br /> EH 23 046 (Revised 07/21/10) <br /> 6 <br />