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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />(209) 468-3420 <br />AUTHORIZATION TO RELEASE <br />• ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAL/STYE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT /' c� <br />(Street Address) fcilfx4e <br />HEREBY AUTHORIZE : . -e—j 61 <br />� <br />oratory or Consultant) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQ UIN 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 NAME: <br />(If Applicable) <br />OWNER/OPERATOR: 4� 1 ' r <br />(Plegse Print) (Title) <br />(Owner/Operator Signature)) <br />ADDRESS: 'la ! /--F / Ae, <br />(Mailing Address) <br />(City) <br />PHONE: <br />DATE: u q kfo <br />EH 23 041 (Revised 7-10-92) Page 9 <br />(State) (Zip Code) <br />