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v 10� <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 /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATO/Rf OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT <br /> (Street Address) (City) <br /> HEREBY ✓ <br /> AUTHORIZE C(S C m <br /> (Laboratory) <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 /> / � 11 r <br /> BUSINESS NAME: �dq �// r/�f. L pox <br /> (If Applicable) /� / f /� <br /> OWNER/OPERATOR: D4` ( tf��n�JC r //��� e� <br /> (Please Print) (Title) <br /> r-�`�c"e.o 7 <br /> (Owner//Oper Signature) /J (Date) <br /> ADDRESS: <br /> (Mailing Address) <br /> j /(q f&46, <br /> ����i(city) ^7 (State) (Zip Code) <br /> PHONE: ( ) � 7)�70 ,9 <br /> EH 23 046 (Revised 11/21/06) 9 <br />