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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> AUTHORIZATION TO RELEASE <br /> *ANALYTICAAL RESULTS <br /> *GEOTECHNICAL DATA <br /> ENVIRONMENTAUSITE ASSESSMENT INFORMATION <br /> 1,THE UNDERSIGNED OWNER ANDIOR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATEDAT 3.45 N <br /> (Street Address) (C'ity) T..-- <br /> HEREBY AIfI'HORJZE <br /> _ McCampb�.Q 4T•al �.ic..� P;���iurr�+�_ <br /> (Laborataryy) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BusrrrEss NAME: `rOAU62 e Co AA AT�� �&P,��►;� <br /> (!f pplicable) <br /> OWNER: 1 p M <br /> L 4 +(d e C la I n <br /> (p a print (Title) <br /> Lner Signaiure) (Dale) I <br /> ADDRESS: — 37(:)7 K , Q '� — <br /> (Mauing Adfdfess) _ <br /> �Q raw*4 r\�a CA <br /> �S gSf <br /> (City) (Srate) (Zip Code) <br /> PHONE:(S W q-72 - Z,{e)© _.,_...,. <br /> EH 23 046 (Revised 02/2OM) <br /> 5 <br />