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NOV-28-2012 17:32 From: 2098254549 To:4683433 Paee:6111 <br /> 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 /> • ENVIRONMENTAIASITE ASSESSMENT INFORMATION <br /> 1,THE UNDERSIGNED OWNER AND/OR OPERATOR Pr THE PROPERTY ANDIOR FA LITY LOCATED AT <br /> (Soret Address) (Cary) <br /> HEREBY AUTHORIZE <br /> (Cabo <br /> rotary) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SANTE TIME IT IS PROVIDED TO ME OR MY <br /> ..� REPRESENTATIVE. 7 <br /> BUSINESS NAME: C PLO-0 A-) <br /> (7jApplicable) <br /> �C OWNER rAM C9 N lz� C a b Gt��v-2h <br /> (Please Print) (7irle) <br /> QI/li r� <br /> (Owner Signature (pat <br /> ADDRESS: <br /> (Mailing Address) ti <br /> C flop <br /> U� (City) (State) (Zip Code) <br /> PHONE: <br /> EH 23 046 (Revised 07/21/10) <br /> 6 <br />