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0 <br />0 <br />ENVIRONMENTAL HEALTH DEPAR <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <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 <br />LOCATED AT C;� D SJDf% IV(57 l L / <br />HEREBY <br />AUTHORIZE (gra &/I <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN <br />ENVIRONMENTAL HEALTH DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT T <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: <br />OWNER/OPERATOR: <br />ADDRESS: <br />PHONE: <br />(If Applicable) <br />i /--,/2 esC /<:�E (—/ S <br />(Please Print) <br />(Owner/Operator &Igngf4Pq) <br />/-� O X G O <br />Address) <br />c Cel - <br />(State) (Zip <br />3 - 7c7 i <br />EH 23 046 (Revised 07/31/08) 9 <br />SAME <br />T- <br />L) <br />c75�03 17 6P� <br />3 7� <br />