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2Dq-qqy `�Z ?7 <br />Join <br />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 />RPSIVE0 <br />NOV 1 9 1993 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT <br />Street Aaaress) / LCG(c.'tryJ �-ve <br />HEREBY AUTHORIZE S G V Wi'�i'�/) G�C �O -% / /%��7-`I 111J—`;P1' H. <br />(Laboratory or Consultant) <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 />Ili UI' • C <br />BUSINESS NAME: <br />(If Applicable) <br />OWNER/OPERATOR: <br />(Please Print) (Title) <br />PHONE: <br />DATE: <br />(Owner/Operator Signature) <br />(Mailing Address) <br />(City) <br />EH 23 041 (Revised 7-10-92) Page 9 <br />ml <br />(State) (Zip Code) <br />