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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 /> " ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNTER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> - -. .x—LQCATED-AT_ — <br /> (Sh-eet Address) (Cit)) <br /> HEREBY AUTHORIZE <br /> (Laboratory) <br /> TO RELEASE A-NY AND ALL.ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY EN—\7IRONMENTAL HEALTH <br /> DEPART�vfENT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR MY <br /> REPRESENTATIVE. <br /> BUSINESS NI AME: <br /> (If Applicable) <br /> OV\TNER/OPERATOR: J hct -4:r- ek x, <br /> (Please Print) (Title) <br /> A�(�\- <br /> (0wucr/6peratorSi 77att0re) (Date) t <br /> ADDRESS: s'�,1c-�� �i' f �`i ,sVe--4' <br /> (Mailing Address) <br /> al- _ I(, D <br /> (City) (State) (Zip Code) <br /> PHONE: u2Q` � -.a :. <br /> EH 23 046 (Revised 10/16/03) Page 9 <br />