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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209)468-3420 <br /> 4 <br /> j <br /> AUTHORIZATION TO RELEASE <br /> * PuNALYTICAL RESULTS <br /> *GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> 1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 5023 Market St _ , T, ndc-n . f'.A QS21A <br /> HEREBY AUTHORIZE <br /> GeoAnal tical Laboratories (City) <br /> (Laboratory) <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 Nk ME: <br /> f Applicable) <br /> " OWNER/OPERATOR: <br /> (Please Print (Title) <br /> r <br /> wne for S gnature l (Date) <br /> ADDRESS: --3coZol W' �G �J-u <br /> (Mailing Address) <br /> (City) / '` (State) (Zip Code) . <br /> PHONE: ( � (� `Z 2- -2 ,-2 '/ <br /> EH 23 046 (Revised 10/19/98) Page 9 . <br />