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Jun.09.2010 10:33 AM PAGE. 3/ 3 <br /> 0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> AUTHORIZATION TO RELEASE <br /> •ANALYTICAL RESULTS <br /> *GEOTECHNICAL DATA <br /> * F..NVIRONMENTAL/SI.TE ASSESSMEN'C INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPER <br /> +,ATOR OF THF PROPERTY AND/OR FACII.TI'Y <br /> LOCATED AT 1() a a Va "\, i a- C-,Y= ° --Q —' \P, N '-� `i '� 3(c <br /> (Street Address) (City) <br /> l <br /> (Laboratory) <br /> TO RELEASE ANY AND All ANALYTICAL INFORMATION TO SAN JOA+QUIN COUNTY ENVIRONMENTAL HFAI,TH <br /> DEPARTMENT AS SOON AS[TIS AVAILABLE AND A' THE SAME <br /> TIME:IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: l N\CO `��k-V _ , <br /> (�fAPPlicablc) <br /> OWNER: <br /> (Please Print) Mlle) <br /> (QWnoT S; rtpture) (gate) <br /> (MrxiTird dress) <br /> VIS c--rx 9S <br /> T [ Ply) (Slide) (Zip code) <br /> PHONE: <br /> FH 23 046 (Revised 02/20/09) <br /> 5 <br />