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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 468-3420 Fax: ( )468-3433 RECEIVED <br /> AUTHOR1ZATION TO RELEASE OCT 3 1 201 <br /> "I-JLT <br /> * <br /> ANALYTICAL RESULTS DEPARTMENT <br /> * <br /> GEOTECHMCAL DATA <br /> * <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> 1,THE UNDERSIGNED OWNER ARID/OR OPERATOR OF THE PROPERTY /OR FACILITY LOCATED AT <br /> (Street—Address) (City) <br /> HE BY AUTHORIZE <br /> ` (Cabo <br /> story) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT TEE SAME TIME IT IS PROVIDED TO MEE OR My <br /> REPRESENTATIVE. <br /> BUSINESS NAME: <br /> (If Applicable) <br /> OWNER: L <br /> —� (Please Print) (Title) <br /> (Owner Signature) (Date) <br /> ADDRESS: Z>T+0 p 775 <br /> (Mailing Address) <br /> - CSC) <br /> (City) (State) (Zip Code) <br /> PHONE:( - '�'i c=� o -z <br /> EH 23 046 (Revised 07/21/10) <br /> 6 <br />