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NOV, 19. 2015 10:26AM N0, 1292 P, 6 <br /> 'ENVIRONMENTAL HEALTH DEPARTMENT <br /> SA N JOA►.QUIN COUNTY <br /> Telephone,(20-9)468-347,0 Fas.;(209)46$13433 RECEIVED <br /> AUT 01 ZATIQN TO ULEASE <br /> NOV 19 2015 <br /> --�- VIRONMENTAL <br /> ANALYTICAL RESULTS u c A 1 TU rirnn r+y r41T <br /> GEOTECHNICAL DATA <br /> '" EN��I�O�LMENTtsLfBITE ASSLSSMEI�IT iNF+OT3�+1.�1TION <br /> 1.TETE.UNDr-ItMONED OWNER ANDIOR OPERATOR OF THL ANDiOR°AC11..11Y LOCAM AT <br /> 5t7 <br /> (Street Address) (City) <br /> JIMREBY AUTHORTZE <br /> (Laboratory) <br /> TO RELEASE,AWY AND ALL ANALYTICAL INPORMATION TO SANT 7OAQT N COUNTY ENVIkONNfENTAT,HEALTH <br /> OEPARTMENT AS SOON AS IT IS AVAILABLE A\D AT THE SANE TIME IT TUROYIDED TO ML OR MY <br /> REPRESLNTAT[Vfi. <br /> BUSINESS NAME: _ <br /> . (7f�PPl�czrhk) <br /> OWNER: _ <br /> (Please Prim) <br /> (Owner Signalurq) (Date) <br /> ADDRESS: <br /> Wailing Address) <br /> � - (City) (State) (Zip Carle) <br /> PHO' <br /> EH 23 046 (Revised OW17/14) <br /> 6 <br />