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0 Fift COPY <br />ENVIRONMENTAL HEALTH DEPNT <br />SAN JOAQUIN COUNTY r <br />Telephone: 4 - 6 - NovVED <br />ph ne (209) 68 3420 Fax: (209} 4 S 3433 � `5 <br />2 <br />AUTHORIZATION TO RELEASE <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />X15 <br />N8imovA <br />FNT <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT <br />1960 W. 11TH STREET <br />(Street Address) <br />TRACY <br />(City) <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 TIME IT IS PROVIDED TO ME OR MY <br />REPRESENTATIVE. <br />BUSINESS NAME: CHEVRON SS#201383 <br />(If Applicable) <br />OWNER: CHEVRON PRODUCTS CORP. <br />(Please Print) (rtle) <br />(Owner Signature) <br />ADDRESS: <br />(Mailing Address) <br />(Date) <br />6001 BOLUNGER CANYON ROAD SAN RAMON CA 94583 <br />(City) (State) (Zip Code) <br />PHONE: ( 925 ) 842-1000 <br />EH 23 046 (Revised 07/17/14) <br />2 <br />