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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 />* 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 <br />(Streel Address) (City,) <br />HEREBY / nO A)4 Z! �^ <br />AUTHORIZE _ C� C, �7 ��(� /jZ <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT 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 />11019ams <br />t 7 DIS %ter /c <br />Print) <br />rv6�T� r«��oiS 6po`i� <br />(City) (state) (Zip Code) <br />PHONE: ( D / 7) clog — 5'o1c) <br />EH 23 046 (Revised 10/30/12) 8 <br />