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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />\ AUTHORIZATION TO RELEASE <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />\EIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/ORERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT161 Z J e- 5',---oN 01 q ra <br />(Street Address) l U (City) <br />HEREBY AUTHORIZE <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATIONSAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE S SA <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: PH 1 Wy m 1— Q 141 X / U <br />(If Applicable) <br />OWNER/OPERATOR: <br />l I ff IF F✓" a F-FjF� <br />(Owner/Operator Signature) <br />ADDRESS: 1612- W. t 4 g m m -et <br />(Mailing Address) <br />Aj <br />q (City) <br />PHONE: <br />EH 23 046 (Revised 8/3/07) <br />4 <br />(Title) <br />12- <br />(Date) <br />Z(Date) <br />CA 5j - a <br />(State) (Zip Code) <br />