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- i <br /> SAN JOAQUIN COUNTY PUBLIC II AMm SERVICES ' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (269) 469-3420 <br /> AUTHORIZATION TO RELEASE <br /> • ANALYTICAL RES LTS <br /> • GEOTECIINICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> 1, 'rIIE UNDERSIGNED OWNER AND/OR OPERATOR OF IIB PROPERTY AND/OR FACILrCY <br /> LOCATED A'I' <br /> Iree1 rens ( ty <br /> HEREBY AUTHORIZE <br /> (Iabonrdory or Consultant) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATI N TO SAN JOAQUIN COUNTY PUBLIC <br /> IIEAI Tkl SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO <br /> ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME : A& JA A <br /> (if e) . <br /> OWNERIOPERATOR ; ', <br /> (0woetlC4wmtor,S1gns1ure) <br /> ADDRESS: <br /> (Mailing A ross) <br /> (c ►y) ( ) 91P) <br /> PHONE: <br /> DA'I_E_.... <br /> r <br /> Pep 9 <br /> !H 23 041 (Rwhld mo-w) <br />