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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 /> * ENVIRONMENTAL/SITC ASSESSMENT INFORMATION <br /> 1,TIME UNDERSIGNCD OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT <br /> 25775 Patterson Pass Road, Tracy <br /> (Street Address) (City) <br /> r-. HEREBY AUTHORIZE <br /> �MV''ra - 1 e <br /> (Laboratory) <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 SAME TIME IT IS PROVIDED TO ME OR MY <br /> REPRESENTATIVE. <br /> BUSINESS NAME: ARP Mini Mart <br /> (IfApplicable) <br /> OWNER: Harshad Patel Owner <br /> (Please Print) (Title) <br /> • <br /> 31112018 <br /> (Owner Signature) {Uute� <br /> ADDRESS: 25775 Patterson Pass Road _ <br /> (Mailing Address), <br /> Tracy CA 95377 <br /> (city) (State) (Zip Code) <br /> PHONE: 51( 0 ) 468.9543 <br /> REGFI `!.! ED <br /> �Y 0 7 21018 <br /> ENVIRONMENTAL <br /> EH230038(revised 7-26-2016) 6 HEP.I_TH DEPARTMENT <br />