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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />(209)468-3420 <br />AUTHORIZATION TO RELEASE <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT /RMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROP RTY AND/OR FACILITY LOCATED AT <br />7 -Eleven #19976 - 1399 North Main Street M nteca - Ca 95336 <br />(Street Address) (City) <br />HEREBY AUTHORIZE <br />n/a <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL FORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SOON AS IT IS AVAI BLE AND A THE SAME TIME IT IS PROVIDED TO ME OR MY <br />REPRESENTATIVE. <br />BUSINESS NAME 7 -Eleven c <br />(If Applicable) <br />OWNER/OPERATOR: <br />lease print) (Title) <br />(Owner/Operator Signature) (Date) <br />ADDRESS: <br />(Mailing Address) <br />(City) (State) (Zip Code) <br />PHON ( 800)828-0711 <br />EH 23 046 (revised 1/24/02) <br />c\sjle\flp\repays3-eh23046.wpd Page 5 Wo #124679 <br />