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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH I51VISI6N <br /> (209) 468-3420 ` <br /> AUTHORIZATION TO RELEASE <br /> li <br /> ANALYTICAL RESULTS i1 <br /> GEOTECHNICAL DATA <br /> j * ENVIRONMENTAL/SITE ASSESSMENTS INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR F THE PROP <br /> ERITY AND/OR FACILITY <br /> LOCATED All _ v� `�y / r <br /> Street Addr s) (City) <br /> HEREBY AUTHORIZE <br /> ( <br /> Oratory) . <br /> TO RELEASE. ANY AND ALL ANALYTICAL INFORMATION TO SAN JQAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION AS SOON AS [T IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE, l <br /> BUSINESS NAME: /C-) W u— > <br /> li (If Applicable) <br /> I �I <br /> OWNER/OPERATOR: <br /> (Please Print) (Title) <br /> ,. a i 1 <br /> I 14 <br /> (Owner/Operator Sign re) (Date) <br /> ADDRESS: (Mailing Address) p <br /> ii <br /> (City) (Stag) (Zip Code) <br /> PHONE: (�%'O ) P 3 �0 3 —���5 GS <br /> i. <br /> 'i <br /> Ell 23 046 (Revised 9/11/96) Pae 9 <br /> ; g <br />