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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />(209) 468-3420 <br />AUTHORIZATION TO RELEASE <br />ANALYTICAL RESULTS <br />GEOTECHNICAL DATA <br />' ENVIRONMENTAUSTTE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT Z� s y L'I <br />(City) <br />HEREBY AUTHORIZE <br />_) (Laboratory or Consultant) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br />HEALTH SERVICES AS SOON AS PT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br />TO ME OR MY REPRESENTATIVE <br />v > 1 <br />BUSINESS NAME:>�nt 1� �� i_ k RC ��x1 iii t <br />(If Applicable) <br />OWNER/OPERATOR: L �- l -V J lUL V C i - `Jr - 1 L) '' t I <br />(Please Print) n J (Title) <br />I- i 3-- ntq 9' <br />i% <br />((0*6ebfCioervMr Signature) ( V <br />ADDRESS: b �- L C'. 'L U, 1, [1,6 i,�� i <� � <br />(MailingAddress) <br />., f /� <br />(City) / (State) (Zip Code) <br />PHONE: ( I (;t ) �' � PIC, <br />DATE: <br />EH 23 041 (Revised 7-10-92) Page 9 <br />