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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 INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY Q <br /> LOCATED AT g3!sS k,,4JKrI� <br /> Loo OQcl �OGk'�Oh e-04i 5^�� <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE L L— <br /> (Laboratory)(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 /> REPRESENTATIVE. <br /> BUSINESS NAME: L(/'Q cy-&0 :54e-C� <br /> (If Applicable) J <br /> OWNER/OPERATOR: 5/e u 61,1 l"fJ rove �3 Pre j CGt �LL4/1ltQ�r <br /> (Please Print) (Title) <br /> (Owner/Operator Signature) (Date) <br /> ADDRESS: f/,Y/ e', l Lacj!C'Ioh 6Zy / 5 2.6-40' 3 2-1 <br /> (Mailing Address) <br /> �=1 k <br /> �} (City) / (State) (Zip Code) <br /> PHONE:( L�(p <br /> EH 23 046 (Revised 10/16/03) Page 9 <br />