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ik <br />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 />* ONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR %RATOIR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT / q/� kv , t G� A"v t �i D G K i o Aj 9t 1,2 0 J <br />(Street Address) (City) <br />HEREBY AUTHORIZE <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SA JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: 14 « wev-b S d- fOV-2 <br />(If Applicable) <br />OWNER: <br />� f <br />r <br />ADDRESS: <br />(Pleas Print) <br />rn� � f <br />(Owner Signature,,)// <br />Al , IiA14M <br />(Mailing Address) <br />q (City) p <br />PHONE:( 9) l S^% 9 70 U <br />OEH 23 046 (Revised 02/20/09) <br />(Title) <br />/(Date) <br />G.An/e . <br />5 <br />(State) (Zip Code) <br />