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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 .Z 1© etf_ h ,� -Fq I''t6�L c ,(�kJ6 <br />(Street Address) (City) <br />HEREBY AUTHORIZE 12'^G �C.L SC/11�i�Z�_�JC11c�� <br />(Laboratory or Consultant) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br />HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br />TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME:='�t�''�7a`CSI�CCr <br />(If Applicable) <br />O WNER/OPERATOR: <br />ADDRESS: _52- � L36t;j- n1t'g_' [ "c <br />(Mailing Address) <br />I-i.6��� C-�8 "732-30 <br />(City) (State) (Zip Code) <br />PHONE: ( 2f" - ) SeZ — a -3 49 <br />DATE: ct <br />EH 23 041 (Revised 7-10-92) Page 9 <br />