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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQU IN 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 FA ILITY LOCATED AT <br /> ? <br /> V05ZM/ -4 MAi <br /> (Skreet Address) (City) <br /> HEREBY AUTHORIZE <br /> 121// 6 1051;F(Labo <br /> ratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNT ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS P OVIDED TO ME OR MY <br /> REPRESENTATIVE. <br /> BUSINESS NAME: J2 Co A YO m <br /> 7j e4�1 tom.. � (If Applicable) 1 NC- <br /> OWNER: Oe ,—A J? ' t'� (- nI'l!'J�pj� <br /> (Please Print) (Title) <br /> (Owner Signature) (Date) <br /> ADDRESS: I —7 2 <br /> (Mailing Address) <br /> M 7 M7E7 C /4 <br /> qq }p,� (City) (State) (Zip Code) <br /> PHONE: o�e9 oZ 3 14--7 15— 9:� ca L1 5 <br /> EH 23 046 (Revised 07/21/10) <br /> 6 � <br />