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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 468-3420 Fax: (209)465-3433 <br /> AUTHORIZATION TO RELEASE <br /> *ANALYTICAI,RESULTS V <br /> *GEOTECHNICA.L DATA <br /> FNI VIRONMENTALiSITE ASSESSMENT IIvFOR:ivir�'CIC? <br /> I,THE UNDERSIGNED OWNER AND10R OPERATOR OF THE PROPERTY ANDIOR FACILITY <br /> LOCATED AT kE> S 0/12 --- <br /> (Str•ee.t Address) (City) <br /> HEMBY <br /> AUTHORIZE- k-2 i`-- <br /> (Laborator;y) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY <br /> ENVIRON.NIENTAL HEALTH DEPARTMENT AS SOON AS IT IS AVAILABLE ANIS AT THE SANTE <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUMNESS NAI(IE: c\j y t)C— C ! <br /> (If flpplicable) <br /> OWNER-/OPERATOR: <br /> ' Tt Intl <br /> (please Print.) (rtle) <br /> (Owner/Operator Signature) (Date) , <br /> AUURESS: Lf V- : ( �.(9..fy..�...i . (c)z) <br /> (tllfailing Address) <br /> (City) (State) ("Lip Code) <br /> EH 23 046 (Revised 10/30172) 8 <br />