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SAI )AQUIN COUNTY PUBLIC HEALTH SER ES <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 THE PROPERTY AND/OR FACILITY <br />7S SP,4-,Tz&w,l <br />LOCATED ATS <br />(Street Address) Q �1 (City) <br />HEREBY AUTHORIZE c Ennw �a(_)d <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <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 />(I.f <br />OWNER/OPERATOR: <br />(Please Print) <br />f�/Y✓ (zD ( <br />Signature) <br />(Title) <br />ADDRESS:-7— <br />DDRESS: /AZ cS��/�L� d1wy(J XxjmC ,_ <br />_ (Mauling Address) <br />(City) - - (State) (Lip Code) <br />PHONE: (V/67 /6 ) [UJ� <br />EH 23 046 (Revised 08/13/99) Page 9 <br />