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I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (2W) 468-3420 <br /> AUTHORIZATION TO RELEASE' <br /> • ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> ENVIRONMENTALlSITE ASSESSMENT INFORMATION <br /> 1. T1 iE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT I 0 ? 4 R F ( Z f hz-i-06-36 LIS :& <br /> (Sime!Address) City) <br /> IIEREBY AUTHORIZE ly��CA�.-ot�ErL i� 1 AC-4-MC,4( _. <br /> ( ) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> I IELTH SERVICES AS SOON AS IT IS AVNLABLE AND AT THE SAME TIME IT IS PROVIDED <br /> '1'0 ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: - <br /> (If A licatk) <br /> OWNER/OPERATOR. Ti9y- r <br /> (Please Print) (Title) <br /> OwaedOperator Signature) <br /> ADDRESS: - <br /> ( aiUng Address/ r��y � <br /> (City) (Stare) (Zip Code) <br /> PHONE: ( 4,as <br /> DATE: I - q �l3 <br /> LII 23 041 (Revisc4 7-1092) PP`o 9 <br />