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SAN JOf ;1W COUNTY PUBLIC HEALTH SERW.00ES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3470 <br /> AUTHORIZATION TO RELEASE <br /> • ANALYTICAL RESULTS <br /> ' OEOTECHNICAL DATA <br /> • ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> L1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 749 S. Stanislaus Street Stockton CA i <br /> eAs,:) (City) I <br /> HEREBY AUTHORIZE eoel nay fcal Laboratorie's <br /> (laboratory or Onsulranl) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br /> LTO ME OR MY RFFRESENTATIVE <br /> BUSINESS NAME: (/ <br /> (If Applicable) <br /> �y O WNER/OPERATOR: G j <br /> L (Please Prier (trifle) 1 <br /> (Uwner/Operator Signature) <br /> ADDRESS: �• �OQ_ ��G G...�..,:...--- — -- <br /> (Mailing Address) <br /> {city) (State) (zip Code) <br /> F <br /> PHONE: 20'1 J ` 6 S•-!�!s--•-- - <br /> L <br /> I <br /> --DATE: <br /> CEH 23 041 (Revised 7-10-92) Page 9 <br />