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0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOA UI COUNTY <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> AUTHORIZATION TO RELEASE <br /> *ANALYTICAL RESULTS <br /> *GEOTECHNICAL DATA <br /> ENVIRONIMENTAUSITE ASSESSMENT WFORMA71,11,N-1, <br /> 1,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT o. /!2 x. <br /> (Streel.Address) (City) <br /> tV) <br /> IfEkEBY <br /> AUTHORIZE <br /> . ..... .. ..... <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEAL'T'H DEPARTMENT AS SOON AS IT IS AVAILABLE AND ATTHE SAME, <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NATvJT-: <br /> (If Applicable) <br /> OWNEWOPERATOR: <br /> 4AllZf-5f:WTAT1UF e <br /> (pie Primo <br /> r <br /> e <br /> (Owner/Operator Signature) (Date) <br /> ADDRESS: 2- PP—AL-W— W0:5T C(IZC-L7f i c') <br /> (Mailing Address) <br /> (city) (State) (Zip Code) <br /> PHONE: LA <br /> EH 23 046 (Rtvised 10/30112) <br />