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S Q N 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 /> (StreetAddidess) Flo) <br /> HEREBY AUTHORIZE <br /> ge. b4) �1INL IC l <br /> (Laboratojy) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT AS SOON AS ITIS AVAILABLE AND AT THE <br /> SAME TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NA E4 : <br /> (/f pplicable) <br /> OWNER/OPERATOR: ; I C 111C�r <br /> (Please Print) (Title) <br /> /� canter/Operraattor Signature) r(Date) <br /> ADDRESS: J J 1 1( 1 (' . <br /> (h4ailingAddress) <br /> rrA <br /> (C ' / /(Shale) (Zip Code) <br /> /� I <br /> PHONE: U9 �. J 1 ( Il q oo <br /> Sof10 <br />