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r <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 O ( L.y , LA I L' L h— S cocl-rove <br /> (Street Address) (City) <br /> HEREBY <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: G Z ii 0�, Srb�IDw —kLLALy pvn, -Y !(I ti c H <br /> jAppltcable) <br /> OWNER/OPERATOR: <br /> (Please Print) (Title) <br /> (Owner/Operator Signature) 1 (((Date) <br /> ADDRESS: _ 4-Z.S a, Le� t)oha�b �T 3N� \enl. <br /> (Mauling Address) <br /> STc,cy--rn1.. <br /> (City) (State) (Zip Code) <br /> PHONE: �Z( O eg )_ 4 3l — 41 <br /> EH 23 046 (Revised 07/31/08) 9 <br />