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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 PROPERTY AND/OR FACILITY <br /> LOCATEDAT <br /> (Street Address) (City) <br /> HEREBY ! <br /> AUTHORIZE IJIM 1"�Tv%-In QJ tot 'c-lAi <br /> g oratory) <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: (2,�TH o� Sc-OGk-ttNn l ,, d ay u l bynAna&� `�w�i <br /> Applicable) `f — <br /> OWNER/OPERATOR: k{ "VOA C2kAbQctAk? <br /> ase ri (Title) <br /> (iTlre er1 for Signature) ( ate) <br /> ADDRESS: 5� F� • 1L� D,�a ( \6oU . <br /> (MailingAddress) <br /> (City) (State) (Zip Code) <br /> PHONE:(Zpg 1 3!1 -—2 S�� <br /> EH 23 046 (Revised 07/31/08) 9 <br />