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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />(209) 468-3420 <br />AUTHORIZATION TO RELEASE <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />pert} -For <br />I, THE UNDERSIGNEDIOWNER OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT <br />G1u1:) 5W <br />(Street Address) (City) <br />HEREBY AUTHORIZE 85T 2j22Eajun6z:a <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: !E5oAl2)na <br />(if Applicable) <br />,Agent -br <br />OWNER/.: <br />(Please <br />Signature) <br />C-ni anMo <br />(Title) <br />(Date) <br />ADDRESS: SC) Howe Avenue, <br />(Mailing Address) <br />ram n�v CA � Z <br />(City) (State) (Zip Code) <br />PHONE: (%1!� Cn _ <br />EH 23 046 (Revised 9/11/96) Page 9 <br />