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.OK <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY E'ECEIVE? <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />AUTHORIZATION TO RELEASE <br />MAF 16 2015 <br />riRn�n n ;ENTAL <br />h�1r TlJ � <br />* ANALYTICAL RESULTS r ollaTimklI <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT `7�K5 i✓o rTy /�F2SH/�� d£ . Srcl&zj G9. 9,5,:>0 <br />HEREBY <br />0?*;) 66 9 o/dv <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 />Mllk&,"$1�L�u I --^A <br />OWNER/OPERATOR: <br />ADDRESS: <br />0 <br />PHONE: gj R 13J, — /4 1, <br />EH 23 046 (Revised 10/30/12) <br />