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L _ <br /> L ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> L <br /> Telephone:(209)468-3420 Fax:(209)468-3433 <br /> L AUTHORIZATION TO RELEASE <br /> ANALYTICAL RESUL'T'S <br /> L •GBOTECHNICAL DATA <br /> MVMOtadNTALASrM ASSESSMENT WORMATION <br /> 1.TMUNDERSIONED OWNER ANDIOR OPERATOR OF THE PROPERTY AND/OR FACILrry <br /> LLOCATED AT 345' N, &,,, 3.aeu,41 3E.��, (,k <br /> (S&vWAddrm) Xv j) —r^ <br /> HEREBY AUMORIZE /� Q <br /> - <br /> `-" _ {Labamtory -r— <br /> TO REXn'cE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COCMTY ENWROMMENTAL HEALT'll <br /> DEPARTMENT AS SOON AS IT IS AVATLAWX AND AT THE SAME <br /> TWE IT IS PROW)ED TO ME OR MY REPRESENTATIYI?. <br /> BUSMWN. ATW: i.�CIS. T co, Aa A-r9 1 <br /> ff lt-ts) <br /> L owNM- 6 <br /> '-e it'd A �a <br /> �t <br /> (title) <br /> Q r <br /> Sfg www) (nate) <br /> L ADDRESS: 7 0 7 ILZKVI; W 0,-y 13 - 15- <br /> (mailing <br /> 3 - 1 5-(mailing Ad#—) 2g— <br /> L <br /> (City) (State) (Mp W4 <br /> PHONE(S TZ Z 2U too <br /> 6. EH 23 046 (Revisad 0712WII9) <br /> L 5 <br /> L <br />