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f <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <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 Q lgs e . <br /> (Street Address) J� (City) <br /> HEREBY AUTHORIZE <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 <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: f ,oc-h0. F000� '�-'7-j FUf- I <br /> (If Applicable) <br /> OWNER/OPERATOR: <br /> (PleasePrint) (Title) <br /> (O er/Operator Signature) , (Date) <br /> ADDRESS: Q I Os E . �cicoo(^14 � - <br /> (Mailing Address) <br /> CA <br /> (City) (State) (Zip Code) <br /> PHONE: ( ac9 ) <br /> EH 23 046 (Revised 8/3/07) <br /> 4 <br />