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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQM COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />AUTHORIZATION TO RELEASE <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENMONMENTAUSTTE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT 2 3 9 3. - - . , f. " n <br />HEREBY <br />(Laboratory) <br />6 j - <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br />TIME IT IS PROVIDED TOME OR MY REPRESENTATIVE. <br />BUSINESS NAME: <br />OWNER/OPERATOR: <br />c r Q <br />(#Ap icable) <br />ADDRESS: 25% Al /t:i /M q A✓,C' <br />(Mailing Address) <br />(State) (Zip Code) <br />PHONE:( 2,51 ) 559- z/s/ <br />EH 23 046 (Revised 07/31/09) 9 <br />;i/Nt %civ <br />