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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />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 AT 11A10? [J �P/G�A3 k)oa-d 'S6lC_4cam/ <br />(Street Address)(City) <br />HEREBY AUTHORIZE so-a'o -c 1QalAlj" /-/«P - <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br />HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: <br />OWNER/OPERATOR: <br />ADDRESS: <br />e <br />(If <br />/el(� ek g S) o s <br />(city) (state) (Zip code) <br />PHONE: ( C207 ) 73/- � 8 5'D <br />EH 23 046 (Revised 10/19/98) Page 9 <br />