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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/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT <br />170 5. 1.Is ��-� St�c�,s,.r �►� SZo� <br />(Street Address) (City) <br />HEREBY AUTHORIZE <br />f� (Laboratory) �7 <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 <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: k.LD iar v f 7rY1 <br />(/f Applicable) <br />OWNER/OPERATOR: <br />Luupq- WW mtTrjt1f, <br />(Please Print) (Title) <br />Signature) <br />ADDRESS: l;0 5, W ►ISqp WAi <br />(Mailing Address) <br />(City) <br />PHONE: ( W'l 1 46(o - uU <br />EH 23 046 (Revised 8/4/06) <br />of) <br />(Date) <br />� 520( <br />(State) (Zip Code) <br />0�1 <br />