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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />(209) 468-3420 <br />AUTHORIZATION TO RELEASE <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 1001 F - q & W Pott M&" F'e czt 6-& 4763340 <br />(Street Addres ) (Cit?') <br />HEREBY AUTHORIZE _ P°�"' 1 r `z r e n a l=' N` /;' ~ -i -11 Z `f M_7 <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: �� �w - I- s s `17', <br />(If Applicable) <br />OWNER/OPERATOR: �vb r jL��,. cry ��`(�.�"rk 'D,Sh!n 11K <br />(Please Print) (Title) <br />(Owner/Operator Signature) (Date) <br />ADDRESS: tt I&iL -77,19- <br />(Mailing <br />7b5(Mailing Address) <br />Vk I,G , &A". d-Ift If 5"1E k Z_ <br />(City)(State) (Zip Code) <br />PHONE: ( 7 0 7 ) tf(,, Z — & E/ <br />EH 23 046 (Revised 9/11/96) Page 9 <br />