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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 />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE ✓PROPERTY AND/OR FACILITY <br />LOCATED AT d � I d l �,, �ek / awl � rwkl-raj <br />Street A�d�dress 1 / 1 <br />HEREBY AUTHORIZE 4��e171 -�1Vlrl1Inen& � X107CG `1-CaZ/ZO%C)L/ "' <br />(Laboratory or Comukant) <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 <br />OWNER/OPERATOR: �An�Y G &nwe� V 1417- <br />VU7o)N35CA <br />(Title) <br />�j/(city) (State) (Zip Code) <br />PHONE: ( C ( -1 ) " (77,q <br />DATE: /G %& <br />EH 23 041 (Revised 7-10-92) Page 9 <br />