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J <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />(209) 468-3420 <br />AUTHORIZATION TO RELEASE <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAUSITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT 305d_ <br />Q3d_ oo 2 <br />(Street Address) 1 (City) <br />HEREBY AUTHO�zE <br />(tel. t TQC �l � � �/►' � o i11�1.Q,;�t.'t-(,j, I 1� <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION 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: V&A f I a o F00 r l <br />(If Applicable) <br />OWNER/OPERATOR: <br />(Please Print) <br />Lor Signature) (Date) <br />ADDRESS: <br />;03a wa4sr(00 <br />(Mailing Address) <br />(City)/�, I (State) (Zip Code) <br />PHONE: Zo LA&7 �0I `Q <br />EH 23 046 (Revised 1/24/02) <br />0 <br />