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SAN JOAQYJIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />AU'T'HORIZATION TO RELEASE <br />ANALYTICAL RES--� U` Lz1'S 1 <br />• GEOTECHNICAL DATA <br />" ENVIRONMENTAL./SITE ASSESSMENT INFORMATION <br />1, THE UNDERSIGNED O' fNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT <br />(Street Address) (City) <br />HEREBY AUTHORIZE <br />f (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 TIME IT IS PROVIDED TO ME OR MY <br />REPRESENTAATIVE. <br />BUSINESS NAME: 7-LIzeL)eW <br />/q q 7( <br />''% / (11Applicable) -- --- <br />OWNER: / ` z �2�L�rl/ _ <br />Print) (i7tle)'�"r� L1l <br />Ykl�I) A� <br />r / ,,,� / � f (owner -Signature) (Date) <br />ADDRESS: 7 ->�G V i5l /� <br />---� s' 6 c i16 > I �U46�c�wij <br />(Mailing dde <br />�D.ox 711 .DofLL.4s -7'X 7522 <br />(city) (Stare) (Zip Code) <br />PHONE:(_ 7z -j p z -F-6 L <br />EH 23 046 (Revised 07117/14) <br />AUG.-'? 2 ZUie <br />