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.v <br /> • Er r` <br /> ENVIRONMENTAL HEALTH DMSION <br /> (2D9) 46$-3470 <br /> AUTHORIZATION TO RELEASE <br /> ` ANALYTICAL RESULTS <br /> ` GEOTECHNICAL DATA ' Y <br /> ` ENVIRONMENTALISITE ASSESSMENT INFORMATION <br /> I <br /> I,'THE UNDERSIGNED OWNER <br /> nn AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 2Z i`0 nt/ Ili n <br /> (Street Address) (cipl) <br /> HEREBY AUTHORIZE Svc v i-V\ &\J. hw.eh �� �2� C r h <br /> (Laboratory or Consultant) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE- <br /> BUSINESS <br /> EPRESENTATIVEBUSINESS NAME: <br /> (If Applicable) <br /> OWNER/OPERATOR: all <br /> In w1 Y1 <br /> (Please Print) qt <br /> ule} <br /> (Signature) <br /> ADDRESS: .O . F)of- <br /> I� (Mailing Address) <br /> mow1 <br /> (c4) (State) (zip code) <br /> PHONE: ( 109 10-79 <br /> DATE: <br /> PAGE 9 <br /> 5 <br /> y <br />