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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 <br />LOCATED AT q3157 C{i�c (�Cr �O o R p q c �oGk h "A 15��5- <br />(Street Address) (City) <br />HEREBY AUTHORIZE <br />it- L <br />(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: bV a�T r &0 <br />(If Applicable) <br />OWNER/OPERATOR: 54,-(! 6/ 1 <br />(Please Print) <br />(Owner/Operator <br />1�s Pre %ce,t <br />(Title) <br />4- ,rActl) D O7, <br />(Dale) <br />ADDRESS: fll/ Z S�dG�CSOH lva�. 5 Z5-O'?jZ1 <br />(Mailing Address) fA <br />(City) (State) (Zip Code) <br />PHONE: ( L ��p ) 4lKy - 6 2� <br />EH 23 046 (Revised 10/16/03) Page 9 <br />