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• 1 r <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <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 // jj •• __ // ��f / <br />D / O 14 4 � AW67 L�9/t� G /L C k 17 -A- <br />(Street Address) (City) <br />HEREBY AUTHORIZE <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN 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: Meg yyiy0 <br />(If Applicable) <br />OWNER/OPERATOR: <br />Print) <br />") L - <br />Signature) (Date) <br />ADDRESS: /6 f Z V4/- 11A,0 JY) <br />(Mailing Address) <br />, e7,� <br />(City) (State) (Zip Code) <br />PHONE: %'-2 — 3 3 70 <br />i <br />EH 23 046 (Revised 1/24/02) <br />2 <br />