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02/20/2005 WED 15:25 FAX 2094683433 SJC EHD --•- Stockton Sery Sta Eq Co vjo06/OUb <br />f <br />I LHEALTH <br />SAN JOAQUIN COUNTY <br />`Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />AurHORIZATION TO RELEASE <br />" ANALYTICAL RESULTS <br />GEOTECHNICAL DATA <br />$ ENVIRONNIENTAL/SITE ASSESSMENT INFORMATION <br />1, THE UNDERSIGNED OWNER AND/OR OPERATOR (' THE PROPERTY AND/OR FACILITY <br />LOCATED AT <br />�_---�---(Sheet address) —_—_ (City)'_:..__..._ <br />HEREBY At MORIZE <br />( aborOfory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN 70AQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SOON AS ITIS AVAILABLE AND AT THE SAME <br />TIME IT IS PROVIDED'I.0 ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: <br />OWNER/OPFRATOR: <br />(P/easeprim) j--- -}----- (Title) <br />(Owner/Operxjor &I"fudre) , (Date) <br />ADDRESS: \ <br />(Mailing Ad"11,ps) <br />(City) (51010) (Zip Code) <br />PHONE: <br />EH 23 046 (Revised 8/3/07) <br />4 <br />13 <br />