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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL 11E:ALTI i DEPARTMENT <br /> (209)468-3420 <br /> AUTHORIZATION TO RELEASE <br /> 'ANALYTICAL RESULTS <br /> `GEOTECHNICAL DATA <br /> " ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> 1,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACUATY <br /> LOCATEDAT a5'19- £. H—y 9 FW , <br /> (Street Addressf <br /> HEREBY AUTHORIZE (City) <br /> (Laboratory) �— <br /> TO RELEASE ANY AND ALL ANALYTICAL MFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME 1T 1S PROVIDED TO ME OR MY <br /> REPRESENTATIVE. <br /> BUSRIESSNAME: SAnmi nt-_'Iti Fqr-n„ 'ny <br /> (1fApplicableJ � --- <br /> OWNEWOPERATOR �.J�ne-H,' F ( i <br /> incase into/ (Title) <br /> / perafor,SignatureJ (Date) <br /> ADDRESS: t S(0 3 e F C.paw�Qq a Q <br /> (Mailing— Addraj) <br /> L. J. CA 9Sa3c. <br /> (City) (State) (Zip Code) <br /> PHONE:(o1OJ 1 [Do7 9.;1ag <br /> EH 23 046 (Revised 10/16/03) Page 9 <br />