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:SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />(209) 468-3420 <br />AUTHORIZATION TO RELEASE <br />• ANALYTICAL RESULTS <br />• GEOTECHNICAL, DATA <br />ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT <br />HEREBY <br />17 <br />V <br />r`ALMH�ORXZE��'S- - - <br />or IRR <br />TO RELEASE ANY`AND ALL ANALYTICAL INFORMATION T"AN JOAQUIN COL' <br />R PUBLIC <br />HEALTH SERVICES AS SOON As rr! is AVAILABLE AND AT THE SAME TIME IT is PIKOVIDED <br />TO ME OR MY REPRESENTATIVE <br />BUSINESS NAME: <br />(If Applicable) <br />OWNER/OPERATOR: -/Old %jA.6g-_ AJWJJSor Stjfllr,) <br />661P� <br />(Please Print) . <br />Pr j IzI4 <br />(Owner/Operator Signai <br />ADDRESS: .525- !/ 74//A'n Com: <br />(Mailing Address) <br />11AA4x'0A<:) <br />(City) <br />PHONE: ( 2 d"I <br />DATE: 7 IZ- Z-114 <br />EH 23 041 (Revised 7-10-92) Page 9 <br />(Title) <br />93 z z 0 <br />