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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/SITEASSESSMEN'T'1NFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR Or THE PROPERTY AMD/OR FACILITY LOCATED AT <br /> 25775 Patterson Pass Roars, Tracy <br /> (Street Address) (City) <br /> V Yo <br /> _ _1 HEREBY AUTHORIZE <br /> 1`ZS'E'.Ci S s CU'� �b1 � <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL.INT:ORMATION 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 NAME: ARP Mini Mart <br /> (If Applicable) <br /> OWNER. <br /> Harshad Patel Owner(Please Print) (Title) <br /> 311/2018 <br /> (Owner Signature) (Date) <br /> ADDRESS: 25775 Patterson Pass Road <br /> (Mailing Address) <br /> CA 95377 <br /> Tracy <br /> - (City) (state) (Zip Code) <br /> PHONE: 51( 0 },-,_ 488'8543 <br /> RECEIVED <br /> APR " 2018 <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> EH230038(revised 7-26-2016) 6 <br />