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C <br />SAN JOAQUIN COUNTYSERVICES <br />ENVIRONMENTAL HEALTH DIV <br />0• f <br />Eywffy-• o �, IN <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 116%—Ior-5 —I t <br />(Street Address) (City) <br />HEREBY AUTHORIZE 2 I�e�tt= <br />(Laboratory " Consultant) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br />HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br />BUSINESS NAME: <br />(If Applicable) <br />OWNER/OPERATOR: yq Wd ee t kL, t t�J i -f c%[1rtl c, t2! <br />(Please Print) w (Title) <br />0 <br />ADDRESS: (Z Z 'S- �C ST tc 1--e1re 17 <br />(Mailing Address) <br />o 1 <204 <br />(City) (State) (Zip Cate) <br />PHONE: <br />EH 23 041 (Revised 7-10-92) Page 9 <br />