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NW, 1./ <br /> 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 /> 1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF TLH. Y A <br /> E PROPER ND/ORF L TY <br /> LOCATED AT l—1�V l.—� �Y�a� t <br /> ` (Street ress) (� (Ci ) <br /> HEREBY AUTHORIZE N — Emvi O ry Z <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> i <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 /> (VApplicable) ,^jJ <br /> OWNER/OPERATOR: <br /> (Please Print) (!Title) <br /> �lzlr� � <br /> (Owner Operator Signat(a/re^l� t+ (D e) d / <br /> ADDRESS: V � © V G�I�. S -7IQSS- <br /> (Mailing Address) <br /> Fadr v,(.. Iq (oD3--7 Cfl3� <br /> (City) (State) P Code) <br /> PHONE: ( b 0) —!7—17 S - 62a S . no i s <br /> i <br /> i <br /> EH 23 046 (Revised 08/13/99) Page 9 <br />