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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 /> * <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> 1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 1153u toes4 Eo 7.+ rn cl 3&C&_- s <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE :Xe? £., +. i I n't I n <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: K'ng r5(c - J R� <br /> (If Applicable) <br /> OWNER/OPERATOR: 'a � nf)�11s Ilan n 1 rr anaa< <br /> (Please Print) �tk) <br /> (Owner/Operator SignatItm) (Pare) <br /> ADDRESS: 11,53b Wes+ £ _r ti s rh i la Ra n <br /> (Mailing Address) <br /> _ S l-oc k i-o^ C44 176 <br /> (City) (State) (Lip Code) <br /> PHONE: ( -20(t ) 3(, 1 <br /> EH 23 046 (Revised 10/19/98) Page 9 <br />