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ti/ Y <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (2W) 468-3420 <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 .1 /l/S W QA/? fenlla -f o G/C 1-ua <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE GeoAnalytical Laboratories <br /> (Laboratory or Comultan!) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE <br /> BUSINESS NAME: <br /> (If Applicable) <br /> OWNER/OPERATOR: d L/ M r /P f U w h e7 <br /> (Please Print) 0 (Tule) <br /> )AI /IX, <br /> (Owner/Operator Signature) <br /> ADDRESS: P U R ar / 2-,LV <br /> (Mailing Address) <br /> �-OsA /hJ3 Ca/t/y/enlf <br /> (City) (State) (Zip Code) <br /> PHONE: (I-Y15' ) C1yk- L ? 1) <br /> DATE: <br /> EH 23 041 (Revised 7-1492) Page 9 <br />