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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 /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> ..J <br /> LOCATED AT �? Ll O O �t II p/I ^a c&1>2s-u-1 Py Testy c4 <br /> (Street Address) (Cit,) <br /> HEREBY AUTHORIZE <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: TY CA.Gla f) V�,— ) In Cr <br /> (If Applicable) <br /> OWNER/OPERATOR: <br /> Na Ya m S) n V Q�7cr �rC <br /> (PI se Print) (Tide) <br /> � c?1 11 <br /> (Owner/Operator Signature) ,/� (Date) h <br /> ADDRESS: � _I O Q I�/ I�C7 C //l� Z/ y (✓ Y <br /> (Mailing Address) <br /> Y C a <br /> /��/ �J City) I (State) (Zip Code) <br /> PHONE: ( a , <br /> EH 23 046 (Revised 8/3/07) <br /> 4 <br />