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u � <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 /> * ENVIRONMENTAUSITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY/� <br /> LOCATED AT � � �. E L 0c f?,% t? JI O G/C / f-N) <br /> (Street <br /> ( Address) (City,) <br /> HEREBY <br /> AUTHORIZEy L4K) C4 � n <br /> (Lab ratory) I�� <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: / <br /> yy <br /> (IjAppkcable) /yfLQ/GG�.tJ iZf,9L £S7 7� /Ntl4S7� -V7- <br /> OWNER/OPERATOR: zyjr L QkWS& <br /> (Please Print) (Title) <br /> 9— rj — /p <br /> erAYperator Signature) (Date) <br /> ADDRESS: -3c& , Q L 0 Cn&2a)7 <br /> (Mailing Address) <br /> 51n) <br /> �(CCiity) (State) (Zip Code) <br /> �In <br /> PHONE: ( & 9_ -J <br /> EH 23 046 (Revised 07/31/08) 9 <br />