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From: 0 1211(0008 16:42 #216 P.002/007 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <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 <br />(Street Address) (City) <br />HEREBY AUTHORIZE <br />(Laboratoty) <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 <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: CI �'!-t �lC. <br />(IfApplicable) <br />OWNER/OPERATOR: <br />.r- <br />(Please Prhit) (Title) <br />(Owner/Operator Signature) (Date) <br />ADDRESS: a--3 -Du,(k Cf -eel<— <br />(Mailing Address) <br />(City) (State) (Zip Code) <br />PHONE: c5P5 -) 9 i � - U g 1 i --- — <br />EH 23 046 (Revised 8/3/07) <br />4 <br />