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uocuoign cnvetope w:U I HOIdbc-raoavuoa-ac w-iau i ouourw�a <br /> • • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> AUTHORIZATION TO RELEAB F-C E I V <br /> ED <br /> BEC 19 <br /> 90 <br /> 16 <br /> *ANALYTICAL RESULTS <br /> *GEOTECHNICAL DATA ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT <br /> 1630 East Hammer Lane Stockton, California 95210 <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> (Laboratory) <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 TIME IT IS PROVIDED TO ME OR MY <br /> REPRESENTATIVE. <br /> BUSINESSNAME: Costco Wholesale <br /> (If Applicable) <br /> OWNER: Dwight Larsen Director of Gas Operations <br /> oxvslonw by: (Please Print) (Title) <br /> I vWqV tI� 12/16/2016 <br /> 83181`87CWEBQD... (Owner Signature) (Date) <br /> ADDRESS: P.O. Box 35005 <br /> (Mailing Address) <br /> Seattle, WA 98124 <br /> (City) (State) (Zip Code) <br /> PHONE:( 425 313-8100 <br /> EH230038(revised 7-26-2016) 6 <br />