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r: <br />Ll <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468--3433 <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />11 ENVIRONMENTAI../SITE ASSESSMENTINFORMATION <br />1, THE UNDERSIGNED OWNER ANA/OR OPERATOR OF THE PROPERTY AND/CTR CACiL.ITY LOCATED AT <br />(Street Address) _ <br />(Cit) <br />HEREBY AUTHORIZE <br />---........... _-_ (Gabo <br />rotor)) <br />TO RELEASE ANY AND ALL ANAI,,YTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO MIG OR 'MY <br />REPRESENTATIVE. <br />BUSINESS NAME: <br />(JfApplicable) <br />OWNER: <br />(Please Print) _ <br />Signatxire) <br />(Til1e) <br />u f► -711 <br />(Dale) <br />ADbRFSS:I--72C� <br />_r (Mailin Address) --- <br />W U 1 <br />(City) (.S,ate) (Zip Code) <br />PHONE, <br />61-123046 (Revised 07/21/10) <br />