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Sn N , J O n Q�U I I N Environmental Health Department <br /> H'!1 C U Il�' '`I <br /> AUTHORIZATION TO RELEASE RECEIVE® <br /> *ANALYTICAL RESULTS MAY 0 9 2013 <br /> *GEOTECHNICAL DATA ENVIRONMENTAL HEALTH <br /> PERMITISERVICES <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT <br /> \aw�vtAerz- Lak,ti <br /> \(_Street Address) City) 1 1 <br /> LCO,j W Ck-hvL a5 71 a1 Cc�M LGw� t DQ ��c FaR 3'_4t �,�b3 <br /> I EREBY AUTHORIZE Vl♦�5313 - 30�' �-S5-zS <br /> 1 S�' a 0-17COL�Cll'c S' 7/-4 -3 <br /> (Laboratory) FLAP WTI' `"Ic1N"v *1 gaSt <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR <br /> MY REPRESENTATIVE. <br /> kUJ�L� n� n - BUSINESS NAME: <br /> S <br /> (IfApplicable) p p rr '' '' <br /> OWNER: 1 S I FO Vee�i 31NLr CS SRM 1 10 �WvCW <br /> (Please Print) (Title) <br /> .,5 ak I y <br /> (Owner Signature) (Date) <br /> ADDRESS: <br /> 1x10 E � wAw� tiCka'a�y <br /> (Mailing Address) <br /> je� i�C",-a"v, Ch-9 5-,? z <br /> (City) (State) (Zip Code) <br /> PHONE: <br /> 6of6 <br />