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SAN J O A Q U I N Environmental Health Department <br /> — COUNTY <br /> AUTHORIZATION TO RELEASE <br /> * ANALYTICAL RESULTS <br /> * GEOTECHNICAL DATA <br /> * ENVIRONMENTAL / SITE ASSESSMENT INFORMATION <br /> I , THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT <br /> 02 L�� 'Yyo p IM Gell lal) - <br /> (Street Address) 1 (Cit}) <br /> HEREBY AUTHORIZE <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR <br /> MY REPRESENTATIVE. <br /> BUSINESS NAM)3 : <br /> c ('A ► n .bbzll Ion I V4sfcn <br /> T A <br /> __ (If pplicab� <br /> OWNER : � z i c+nz &55011/1 �� fCe P�t'eS I �P✓I <br /> (Please Print) (Title) <br /> (Owner Signature) (Date) <br /> ADDRE S : <br /> 2 B 60 �) 5avi f i Qo� o g ( ��ro t c ,� q2% 7 <br /> (Mailing Ad cess) <br /> (city) (State) (Zip Code) <br /> PHONE: <br /> c 71K ?� L512L <br /> 6of6 <br />