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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 />* ENVIRONMENTALISITE ASSESSM NT INFORMATION <br />1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT 1 J : <br />(Street Address) (City) <br />HEREBY AUTHORIZE " <br />(Laboratoryfj <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 ITS IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />11 <br />BUSINESS NAME: <br />(If Applicable) <br />OWNER/OPERATOR : ` VIA,, SL4 0- <br />C. <br />e e nt) (Title) <br />(Own /Operator Signature) are) <br />ADDRESS: <br />Address) <br />3 5 (City) <br />PHONE:( )_ <br />EH 23 046 (Revised 10/19198) Page 9 <br />o _6 ` <br />(State) (Zip Code) <br />