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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 /> LOCATED AT 92-1 1I3j?n b11 CA'-V :tVTL r. m,%%A1tVc_y4 <br /> (Street Address) (City) <br /> HEREBY <br /> AUTHORIZE 't�e �( <br /> I (Laboratory) <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 TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: ( }N cA� 0f\c�TVLlt� <br /> (YAP licable) QA12�S ,,p <br /> OWNER/OPERATOR: �� ('v\'^f ���T UPc�vLaT\'cv) I'UvA(eat <br /> (Please Print) (Title) <br /> (Owner/O``peratorSignature) (1 (Date) <br /> ADDRESS: 2LA< N IAkctm l2A <br /> (Mailing Address) <br /> IM r1,\,t tz c.V R 3 Z,!, <br /> (City) (State) (Zip Code) <br /> PHONE:( 7-0(1 ) ltSQL - `Dl Zn <br /> EH 23 046 (Revised 07/22/10) 8 <br />