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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DMSION <br />(209) 468-3420 <br />AUTHORIZATION TO RELEASE <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT S7 G� J l L UJ i7, Q 1 QAC it <br />(Street Address) s(City) <br />HEREBY AUTHORIZE G,z_04t,j AC T-1 GA k vi -os- lLA—ISAS AV /"IQfJt=STn CA <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 S / ,�/ - (�'d H/WT <br />(If Applicable) <br />OWNER/OPERATOR: SA7A_,A-1Vj ��N�fi CJ✓/�'.E/2 <br />(Please Print) <br />(Owner/Operator 5 <br />ADDRESS: e7 7`f A/ <br />(Mailing Address) <br />-7;�_, <br />(City) <br />nature! <br />C4 <br />(State) <br />PHONE: ( 1 -7) e3 3 3 — 3 <br />EH 23 046 (Revised 10/19/98) Page 9 <br />(Title)) <br />/ <br />(Dare) <br />A, <br />9,5_3 7� <br />(Zip Code) <br />