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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3420 <br /> AUTHORIZATION TO RELEASE <br /> « ANALYTICAL RESULTS <br /> « GEOTECHNICAL DATA <br /> « ENVIRONMENTAIISITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AMD//OR OPERATOR OF THE PROPERTY AND/OR JF�A�CIILIITY <br /> LOCATED AT 05 1���A wJ `� I <br /> (Street Address) (Cary) <br /> HEREBY AUTHORIZE C' Ax�'SD I "�' <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: 2 A"e� ��T <br /> (If Applicable) , M <br /> OWNER/OPERATOR: 6q)z L) �— <br /> (Please Print) (Tirle) <br /> i\am4�Ii�C eSylTrAad <br /> cattner/O for S gnature) (Date) <br /> ADDRESS: � D C�� O- '\1�c — <br /> (Mailing Address) <br /> 1. (Ciry) pL (State) (Ztp Cade) <br /> PHONE: ( O� NpJ 0 T 5 2 <br /> EH 23 046 (Revised 7/10i%6 Page 9 <br />