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SA OAQUIN COUNTY PUBLIC HEALTH SE CES <br />ENVIRONMENTAL HEALTH DIVISION <br />(209) 468-3.120 <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 ROPERTY AND/OR FACILITY <br />LOCATED AT ®62Z29N! �L / <br />(Street Address) Q �11� �/ �jCity) <br />HEREBY AUTHORIZE C / _/'�o/�f7i� l /7`� <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br />HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: �geo/ <br />- (If Applicable) <br />OWNER/OPERATOR: <br />ADDRESS: <br />(Please Print) <br />m <br />Signature) <br />(Mailing Address) <br />t,M �} 90623 - % c(a <br />(City) (State) (Zip Code) <br />PHONE: ( 530) 6ZI— 0*220 <br />EH 23 046 (Revised 08/13/99) Page 9 <br />