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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN J'OAQM COUNTY <br /> Telephone:(209)468-3420 Fax: (209)468-3433 <br /> AUTHORIZATION TO RELEASE <br /> •ANALYTICAL RBSULTS <br /> *OBOTECHMCAL DATA <br /> * ENVIRONMENITAL/SrfB ASSESSMENT INFORMATION <br /> 1,THE UNDF-RSIONRD OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FA CILITY <br /> LOCAT®AT <br /> 345 N. TaQpan S64LA. Ch <br /> (Sammi Add—s) ( �— <br /> HEREBY AUTHORM <br /> 6ufn <br /> (Zaboretory —�— <br /> TO RELEASE ANY AND ALL ANALY77CAL INFORMATION TO SAN 7OAQUIN COUNTY ENV=NivfF.NiTAL HEALTH <br /> DEPARTMENT AS SOON AS rr fS AVAR ABLE AND AT THE SAME <br /> TIME IT IS PROVMBD TO ME OR MY REPRESENTATIVE. <br /> [11ci.�ls 4 �3. f�PA1e1 <br /> susrNassNAMB. <br /> awNBR: <br /> /PimdffPi*gf rltt/e) <br /> 1121 Lg^_� — 0q - <br /> -to", I (ofter <br /> Q — <br /> er Signature) (Date) <br /> ADDRESS 3 707 V- �. 3 <br /> � f <br /> r,�raaln.g. ) <br /> CA <br /> (City) (Blare) (Zip Code(E�l <br /> pKON>r A lG 4`7 Z 2.4 e)n _ <br /> EH 23 046 (Rcviad 02/AW) <br /> 5 <br />