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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <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 �(r7 S /7`�/�8�� L'7' "r/O/ <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE (57E©,0 4Z�Z Tic-p L <br /> (L oratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR MY <br /> REPRESENTATIVE. <br /> BUSINESS NAME: /)` � <br /> (If Applicable) <br /> OWNER/OPERATOR: {' CLC Ile �1 <br /> (Please Print) (Title) <br /> 9�0d <br /> jaw / Pe or Signature) o (Date) <br /> ADDRESS: / D OX /o� / <br /> (Mailing Address) <br /> �✓c�1/),36[/l7�f' Com- �l�'iS�P' <br /> (City) (State) (Zip code) <br /> PHONE:( 20!2 ) 3 3 414�1� <br /> EH 23 046 (Revised 10/16/03) Page 9 <br />