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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />AUTHORIZATION TO RELEASE <br />ANALY FICA 1, RESULTS <br />GUOTECHNICAL DATA <br />ENVIRONMENI'AIAS11'E. ASSESSMENT INFORMATION <br />t -r OP OP <br />_trX'71 IF PROPERTYAND/OR FACILITY! OCATEDAT <br />dlen -- --------- <br />0,71,111 �A <br />HEREB Y :At j*11HO RIZL <br />Arl vc, <br />`FO RELL"ASE, ANY AND ALL ANALYTICAL INI`ORMA I ION TO SAN JOAQUIN COUNTY 1,NVIRONMEN-1 A]. HEALTH <br />DEPARTMENT AS SOO, N AS IT IS AVAILABLE AND AT* 114L SAME TIME IT IS PR[)VIDE'DTO ME OR MY <br />REPRE'SUNI*ATIVE. <br />B t IS [NESS NAME'� <br />(if A pplicabkI <br />OWNER: <br />(Plemse Prina <br />(OwnerSignature)- <br />ADDRE.SS: <br />(Alaiting Address) <br />PHONE <br />EIFI23046 (Revised 07117/14) <br />6 <br />03 <br />{:State) 01, Code) <br />UJ <br />Cka e r <br />