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SANJOA QUINCOUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> (209)468-3420 <br /> AUTHORIZATION TO RELEASE <br /> ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> ENVIRONMENTALISITE ASSESSMENT INFORMATION <br /> 1,THE UNDERSIGNED OWNER ANDIOR OPERATOR OF THEPROPERTY AND/OR FACILITY <br /> LOCATED AT <br /> (StreetAddmss) (City) <br /> HE AUTHORIZE / <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFO TION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: <br /> (lAppilcaue) <br /> OWNER)OPERATOR: <br /> (ple7ase (Title) <br /> ner <br /> 0 aj", <br /> wn peva <br /> alure) (Date) <br /> ADDRESS.- <br /> (Uaihng Address) <br /> c:,,—s 67-,k�, q070S <br /> (City) (State) (Zip Code) <br /> PHONE:( -7i4 - ,:5j 1 -4-o <br /> EH 23 046 (Revised 1/24102) <br /> 6 <br /> L296tp2629S H331W0EIbU3 WU20 :6 9002 la qaj <br />