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ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3420 <br /> AUTHORIZATION TO RELEASE <br /> ' ANALYTICAL RESULTS <br /> • GEOTECHNICAL DATA <br /> ' ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> 1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 126 S. Main, Lodi , CA <br /> (Street Address) <br /> HEREBY AUTHORIZE GeoAnalytical Laboratories Why) <br /> (Laboratory or TO RELEASE ANY AND ALL ANALYTICAL INFORMConsultant) <br /> INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: <br /> (If Applicable) <br /> OWNER/OPERATOR: Frederick R. Mayers Owner <br /> (Please Print) (Title) <br /> (Signature) <br /> ADDRESS: 23575 N. Elliott Rd. <br /> (Mailing Address) <br /> Acampo, Ca. 95220 <br /> (City) (State) (zip code) <br /> PHONE: 20( 9 ) 368-6495 <br /> DATE: <br /> 2120/92 <br /> PAGE 9 <br />