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SAN JOAQUIN COUNTY PUBLIC HEALTH SEh.ICES <br />ENVIRONMENTAL HEALTH DIVISION <br />(209) 468-3.120 <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 <br />`�/�(S,"treet Address) (Cin) <br />HEREBY AUTHORIZE QYI.I✓�1'"V✓DOG{ "borailtry Lncr G7�' Stotkt� SCv-4G4 ftX17 +, , 7-23 os) <br />(Laboratory) ' <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br />HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: —fr—. <br />OWNER/OPERATOR: �����\U� Lt) LtxS �YU�r�StaUil�tc ., A1C,\y\a.ae,( <br />(Please Print) (Title) 11) <br />(Owner/Operator Signature) (Date) <br />ADDRESS: <br />(Mailing Address) <br />cfl c1z1Qc6 <br />(City) (State) (Zip Code) <br />PHONE: QdCA_b i `�Gl i�.- <br />EH 23 046 (Revised 08/13/99) Page �j <br />