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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 />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED A 1801 WEST 11th STREET <br />TTANK)1987 WEST 11th STREET, TRACY CA <br />(Street Address) <br />HEREBY AUTHORIZE <br />(City) <br />(Laboratory) <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 <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: <br />OWNER: <br />STAN OLEA c/o SAFEWAY, INC. <br />ADDRESS: <br />(If Applicable) <br />FUEL CENTER OPERATIONS MANAGER <br />(Please Print) (Title) <br />(Owner Signature) (Date) <br />5918 STONERIDGE MALL ROAD <br />PT.F.ARANTnN <br />(Mailing Address) <br />(City) <br />PHONE:( 099 ) 467-2707 <br />EH 23 046 (Revised 02/20/09) <br />CA <br />• :: <br />(State) (Zip Code) <br />