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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 /> * ENVIRONMENTALISITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT <br /> S` 11 e11, <br /> ' HEREBY AUTHORIZE (Street Address) (City) <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> 1 DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR MY <br /> REPRESENTATIVE <br /> BUSINESS NAME U n tr[m.f L-czVAcz n/ <br /> I -1(IjApplrcable) <br /> OWNER/OPERATOR <br /> (Please Print) (Title) <br /> ' (Owner/Operator Signature) (Date) <br /> ADDRESS ell Al 4c a t-c r <br /> (Mailing Address) <br /> 9400LloA C-4 <br /> (City) / (State) (Zip Code) <br /> ' PHONE ( 20 ) 9 If/—&3rS'? <br /> PEH 23 046 (Revised 3115102) Page 9 <br /> 1 <br /> r <br />