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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 OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT Z 5-45 /""mW .`t <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE S,„r <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR MY <br /> REPRESENTATIVE. <br /> BUSINESS NAME: C u 7 eLLA-i? �'PeZi <br /> (If Applicable) <br /> OWNER/OPERATOR: SMELL QqL pa�� �,�- -T' HO AJ•6�2 <br /> (Please Print) itle) <br /> (Owner/Operator Signature) (Date) <br /> ADDRESS: �/Y-I i� At <br /> (Mailing Address) J <br /> 9S6z � <br /> (City) // (J (State) (Zip Code) <br /> PHONE:( , C� a �. �o/ L Y, <br /> EH 23 046 (Revised 10/16/03) Page 9 <br />