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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <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 ;74 'Z/ �• /,1i'Z�„�/Joc.t7�� ;4G�i��x� <br /> (Street Address) -- (City) <br /> HEREBY / u� S <br /> AUTHORIZE L� Tac)�o <br /> (Laboratory) <br /> Tii RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: �y <br /> I Applicable) <br /> OWNER/OPERATOR: <br /> Please Print) (Title) <br /> caner/Operator Signature) (Date) <br /> ADDRESS: T Q 1,56y Soo I D <br /> (Mailing Address) <br /> (City) (State) (Zip Code) <br /> PHONE: <br /> EH 23 046 (Revised 10/30/12) 8 <br />