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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 ' y <br /> LOCATED AT �/ 6 Al,/✓ e0LgeA0,6 57 (I5�(� Ce- <br /> CAL TF,c%6i;t �is1/t�.J�IF.,,TgL (city) <br /> HEREBY <br /> AUTHORIZE <br /> 62- <br /> 2-7� 2-7o�J <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 /> (If Applicable) <br /> ifals C/ T� Or Sl©c%Tom/ TA�J' �.� C�Tsi SiiJ£fJ��/� <br /> (Please Print) (Title) <br /> r/ perator StgnTve) te) <br /> ADDRESS: F <br /> (Mailing Address) <br /> ST c�T.J i C� 9020 2 <br /> p(City) (State) (Zip Code) <br /> PHONE:( o20 <br /> EH 23 046 (Revised 12131/07) 9 <br />