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SAN ,%QUIN COUNTY PUBLIC HEALTH SERVICt3 <br />ENVIRONMENTAL HEALTH DIVISION <br />(209)468-]420 <br />AUTHORIZATION TO RELEASE <br />• ANALYTICAL RESULTS <br />• OEOTECIINICAL DATA <br />ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />1, 111E UNDERSIONED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT 303 E. Kettleman Ln., Lodi, CA <br />(Street Address) (City) <br />IIERFRY AU'I'IIORIZE GeoAnalytical Laboratories <br />(lehernfory) <br />10 RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br />IIF-AL*I II SERVICES -ENVIRONMENTAL IIEALiH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME <br />MME I I' IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />IIUSINESS NAME: <br />(ll <br />OWNER/OPERATOR: <br />ADDRESS: 1912 E. Mettler Rd. <br />(Afellln8 Address) <br />Lodi, CA 95242 <br />(City) (Store) (Lip Code) <br />PIIONE: ( ;-'6 ) -'!>'3 V— S. V - 2� <br />Elf 2_1 046 (Revised 9/11/96) Page 9 <br />