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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'SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND///OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 7 / S /Vo J`TUN 794?- �� <br /> (Streer Address) (Cm) <br /> HEREBY AUTHORIZE Al G�/� 114pnE� A-AJA C" 7 /C�4C_ -- <br /> (Laborata ) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: <br /> ((f Applicable) ( / <br /> WNER/ ERATOR: yl t l c � <br /> [e a Print) (T'ule) <br /> 3 -1Z ^ C� <br /> (Owne Operator Signature) (Dare) <br /> ADDRESS : <br /> (Mailing Address) <br /> (City) (Stare) (Zip Code) <br /> PHONE: { 2 a <br /> EH 23 046 (Revised 10/ 19/98) Page 9 <br />