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r� <br />L <br />11 <br />Telephonc: (209) 468-3420 Fax: (204) 468-3433 <br />AUTHORIZATION TO RELEASE,' <br />* ANALYTICAL RPSUL CS <br />* 61 011 CI INICAL, DATA <br />* 1-"NVIItONMI;N"I'AI../SI'1'1,ASSI?SSMI'-N'I' INI,'ORMA'I'ION <br />I.'I'IIf'' IJNI)I IZSIGNL•I) OWN1 R ANI)/OIZ 011FRAT01Z 01"I'l li: PROPERTY AND/OR FACILITY LOCATED AT <br />_..._....._...`,_...._L` t. p 0..-._._ C ... Ci a <br />(Street lIddress) (C.'ityJ <br />LI1 RI-l`BY AUTLIORILI" <br />__....._..____-.-.--.-..._.-...__._...--_---................__...__...._--_..__......_._........_.__._......._. <br />E i= q-- o. L -,,o -A Ci t. -�---- --- _.... -- ... ___(Labo <br />ratm y) <br />TO RELEASE ANY AND ALL ANALYTICAL, INFORMATION "1'O SAN JOAQUIN COUNTY I NVIRONMENTAL HEALTH <br />DEPAR'T'MENT AS SOON AS IT IS AVAILABLE AND A"I• "1'111: SAME "1'IME I"I' IS PROVID1:iD "I'O MI." OR MY <br />REPRESENTATIVE. <br />BUSINESS NAME: TYr.,S, V-Ao /V , lar (' ! S2-- <br />- - - - - --__....._._............... ... ................_.... ........... --- ---------- - -- - ---- .. <br />(�f Aplglkable) % <br />OWNER:_7-1-S.00-a EZsc�GaN�N ltiC-fc: tej i,► <br />(Please Print) <br />(Owner Signature) <br />ADDRESS: i9 LO O 'iC�i>�scs vQ+�rA T��r -cC w <br />F/_`.1. <br />(Date) <br />(I /ailing Address) <br />..-.--.......--- . - -- -- - - - - <br />r (City,) (S'tate) (/i/,7 Code) <br />PHONE; {..ZiO__ )._.�.1-��' ----- --- -- -- --- ----------- - _..... _ ._._.. <br />EH 23 046 (Revised 07/21/10) <br />0 <br />