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�� s N•�oAQUZN COUNTY 'PUHL.IC HEALTH SERVICES t <br /> ENVIRONMENTAL HEA?�, <br /> DIVISION <br /> (209)1468-3 <br /> AUTHORIZATION TO RELEASE <br /> F i <br /> } * ANALYTICAL RESULTS <br /> 1 <br /> I f * GEOTECHNICAL DATA <br /> f • <br /> fi <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> h :I <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF,] ROPERTY AND/OR 1 � � THE PR FACILITY <br /> f LOCATED AT qq � I <br /> (Street Address <br /> HEREBY AUTHORIZEJ. <br /> (City) <br /> orato <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMAToratoION TO''SAN 10AQUIN COUNTY PUBLIC <br /> HEALTH SERVICES-ENVIRONMENTAL HEALTH DNISIO�N <br /> AS SOON AS IT IS AVAILABLE AND AT THE S. <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE'. <br /> f <br /> t <br /> BUSINESS NAME: r j <br /> I <br /> f <br /> f' If APP-1 Cole) <br /> OWNE PERATOR: II' <br /> i'k t <br /> ' (Please Prin) L/ ff14L ( <br /> (Title) <br /> I` <br /> (Owner/Operator Signature) <br /> (Date) <br /> ADDRESS: q. <br /> (Mailing Address) f <br /> C <br /> j ( �} , I (State) (Zip Code <br /> I PHONE: { �D?) <br /> i <br /> k <br /> f <br /> I'I <br /> j <br /> EH 23 046 (Revised 9/11/96) 1 , <br /> Page 9 <br /> •i <br />