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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY RECEIVED <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />AUTHORIZATION TO RELEASE OCT 21 2011 <br />ENVIRON OEN AL HEALTH <br />* ANALYTICAL RESULTS PERMIT/SERVICES <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER NER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT - I _�-tR.u�— � �� JL`-"—) G'' � -- <br />(Street Address) (City) <br />1 <br />HEREBY 0n <br />AUTHORIZE *fl <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: <br />OWNER/OPERA <br />ADDRESS: <br />) a& ky) � <br />(If Applicable) <br />, C <br />(Please Print) ; <br />Iwuer/Ope o wig <br />(Mailine, Address) <br />(Title) <br />(Date) <br />6d <br />(City) (State) (Zip Code) <br />PHONE: ( ;0q ) It <br />EH 23 046 (Revised 07/22/10) 8 <br />2.v i. <br />