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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> (209)468-3420 <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 FACIILITY <br /> LOCATED AT Q 1 1 Fe Aj' ��rckfr&l <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE T L, <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 /> BUSINESS NAME: y 2 N He I tl-T— 1y + <br /> (If Applicable) <br /> ff <br /> OWNERIOPERATOR: e i ! fed, G '� <br /> (Please Print) (Title) <br /> TO I'1+ 5 (Owner/Operator Signature) �j! (Date) <br /> ADDRESS: 1 �� �fC-( r� n( P!v No, — <br /> (Mailing Address) <br /> (City) (State) (Zip Cade) <br /> PHONE: IT I <br /> EH 23 046 (Revised 10/16/03) Page 9 <br />