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• <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DMSION <br />(209) 468-3420 <br />AUTHORIZATION TO RELEASE <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />DEC U7 1998 <br />­,, _VAL HEALTH <br />PE -_i' liviIT / Si=;V10EES <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT <br />(Street Address) QQ (City) <br />HEREBY AUTHORIZE _ A it J17 -E Y -WR <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br />HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: <br />(If Applicable) <br />OWNER/OPERATOR: J�dL`,*04 -s, ��'�rJ6�ClL� cA ,; cP LTfn �_T-_ 6v///1i)4�r ,7 <br />(Please Print) (Title) <br />ADDRESS <br />(Mailing Address) <br />h„f Ile <br />(City) <br />(City) (State) (Zip Code) <br />PHONE: ( dd <br />23/-fr9/ <br />EH 23 046 (Revised 10/19/98) Page 9 <br />