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ENVIRONMENTAL HEALTH DIVISION <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 FACILITY <br /> LOCATED ATIncilsl <br /> (S�trc-Yct Addre s) (City <br /> HEREBY AUTHORIZE / r40 � � �(C/4 L//9- ntP <br /> (Laboratory or Consultant) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC, <br /> HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> ------------- <br /> BUSINESS NAME; L^L VA, <br /> OWNER/OPERATOR: (if <br /> -�lI/ 1 &Y <br /> (Please Print) <br /> (Si nature) I <br /> / --- T--- <br /> ADDRESS: A)r I lQ ---- --- <br /> ( ailing Address) <br /> o 1,4 70 <br /> (City) (Stare) (zip code) <br /> PHONE: (209 )- _2,FV <br /> DATE: -2 1 �- <br /> PAGE 9 <br />