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orf i <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 <br /> AUTHORIZATION TO RELEASE <br /> i <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 237 S' <br /> (Street Address) (Cid) <br /> HEREBY — O4 A. <br /> i �AUTHORIZE_--1U <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL ASOON AS IT ISN TO SAN AVAILABLE ANDA THE SAME <br /> ENVIRONMENTAL HEALTH UNTY <br /> DEP <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: <br /> (IfAp icable) <br /> OWNER/OPERATOR: 6-1, " (Title) <br /> (Pl ase Print) <br /> (Owner/ . erator Signature) (Date) <br /> ADDRESS: 2 5 '� Al' <br /> (Mailing Address) <br /> (City) (State) ("Lip Code) <br /> PHONE: <br /> EH 23 046 (Revised 07/31/09) 9 <br /> ---------_ - <br /> :. :;;:::: ... :. <br />