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• <br />• <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />(209) 468-3420 <br />Ni'momm-0 <br />Mid <br />0 ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />1. THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT loot 1-e <br />(Street Addresp (a <br />HEREBY AUTHORIZE seo_rl±l LAhor,&fwr,e_c 30,;_0 <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 />BUSINESS NAME: _ZWA4,&,V1- <br />(If Applicable) <br />OWNER/OPERATOR: 124;710arj_ 1). S 1-r, V ,L h !n 2 <br />(Please Print) (Title) <br />Al", F X/ P /!j <br />(Owner/Opemtoe Signature) (Date) <br />ADDRESS: To Ovg <br />(Mailinj A&rem) I <br />z -- <br />(City) (State) (Zip Code) <br />PHONE: ? 0 7 jo-X r L9 <br />EH 23 046 (Rcvised 9/11/96) Pagc 9 <br />