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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 />f, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT <br />257MPMgp.gmfo"A@41�baTi,al�bAdyACK§9377 <br />(Sit -eel address) (City) <br />HEREBY AUTHORIZE <br />MccA4a6®m1a��r�naf�iaab i�c. <br />(Laborator}) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR MY <br />REPRESENTATIVE. <br />BUSINESS NAMFCQRfg�pgiTAJSgAgAF2�InLnc. <br />(If applicable) <br />Es <br />ADDRESS; U50 Meacham Road <br />(Please Print) (Title) <br />(Owner Signature) (Date) <br />(Mailing address) <br />Bakersfield, CA 93314 <br />Bakers ie (City) (State) (Zip Code) <br />PHONE: ( 661 631-3870 <br />EH230038 (revised 7-26-2016) <br />R ECEI�6ED <br />JUN 08 2017 <br />ENVIRONMENTAL HEALTH <br />6 DEPARTMENT <br />