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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />(209) 468-3420 <br />AUTHORIZATION TO RELEASE <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER &,;,--t <br />AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT r7 01 C � O i( To t, I,f� c't / ✓ _fa�� _7�9/v <br />(Street Address) / (City) <br />HEREBY AUTHORIZE P pe�i f <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br />HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: <br />OWNER/OPERATOR: <br />ADDRESS <br />(If Applicable) <br />(Please Print) <br />(Owner/Operator <br />74l 10sr C <br />(Mailing Address) <br />6yoce) <br />V C. <br />(Title) <br />(Date) <br />T61, -� �- eg 9� 70 <br />(City) (State) (Zip Code) <br />PHONE: <br />EH 23 046 (Revised 9/11/96) Page 9 <br />