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0 0 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />(209) 468-3420 <br />AUTHORIZATION TO RELEASE <br />• ANALYTICAL RESULTS <br />GEOTECHNICAL DATA <br />ENVIRONMENTAL (SITE ASSESSMENT INFORMATION <br />Iy THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT <br />HEREBY AUTHORIZE <br />STocV--For I <br />(Laboratory or Consultant) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br />HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br />TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: F. - -z GjF l2lG <br />(If Applicable) <br />OWNER/OPERATOR: V2Ll-� rO f:�,Pj <br />(Please Print) (Title) <br />DATE: <br />(Owner/Operator Signature) <br />I_\a30 9111 �YJ <br />PHONE: ( l 3 ) kPQ)4 - 4-�, p <br />EH 23 041 (Revised 7-10-92) Page 9 <br />W <br />2`12 <br />Code) <br />