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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />(209) 468-3420 <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 12 Z j f:Z7 L c cj< (—o a/' t'7 Lo a <br />(Street Address) (City) <br />HEREBY AUTHORIZE <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: <br />(If Applicable) <br />Ste► moi= a:'i <br />OWNER/OPERATOR: �yy( t?i e:< i„)t 1-1 <br />(Please Print) t (Title) <br />wen k <br />Signature) (Date) <br />ADDRESS: _('Z ? 4&2 Lc c- i C a= c� , o <br />(Mailing Address) <br />(City) (State) (Zip Code) <br />PHONE: () '?i -g <br />EH 23 046 (Revised 7/10/96) Page 9 <br />