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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 />* ENVIRONMENTALISITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED ATC t �� �Q�PO <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 />OWNER/OPERATOR:Vkff VC:d -(�IAIAA <br />C'� UAV ell - <br />(If Applicable) <br />(Please Print) (rtle) <br />(Owner/Op for Signature) (Date) <br />ADDRESS: <br />(Mailing Address) _ <br />(City) /- (State) (Zip Code) <br />PHONE: ( 2 I) `- t lG� tV <br />EH 23 046 (Revised 10/19/98) Page 9 <br />