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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 CZE I �' ��D 9L\ff7 <br /> (Street Address) 7r(C111) k <br /> HEREBY AUTHORIZE QoYAiJQ r D 7ay, 1961E1 j /v� oTe�w � <br /> (Laboratory or Consu rant) <br /> TO RELEASE ANY AND ALL ANALYTICAL 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: it re e� -�r'•� � ��t� � ' <br /> (If Applicable) <br /> OWNEWOPERATOR: <br /> L i (Please Print) (Title) <br /> (Owner/Operator Signature) <br /> ADDRESS: �� / /G�f —r—Gzicfil CA <br /> (Mailing Address) <br /> (City) (State) (Zip Code) <br /> PHONE: <br /> DATE: <br /> �— (r—c7C <br /> EH 23 041 (Revised 7-10-92) Page 9 <br />