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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 />\3 b S. W;\ so % S o c <br />(Street Address) j j' (City) <br />HEREBY AUTHORIZE I / <br />TO RELEASE ANY AND ALL A AL TIC L INFO ION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SO%TOOR <br />A ABLE AN AT THE SAME <br />TIME IT IS PROVIDEY REPRES TATIVE. <br />BUSINESS NAME: <br />(If Applicable) <br />OWNER/OPERATOR: <br />�&%A ce 1p- % m C.. okt bexe c �\ Pa(k tees <br />(Please PrVN (Title) <br />ADDRESS: ;% VS <br />(Owner/Operator Signature) <br />S• W ��Syn <br />(Mailing Address) <br />(City) (State) <br />(Zip Code) <br />PHONE: ( ZOO) lF(fl(o — 6 - <br />EH 23 046 (Revised 8/4/06) <br />4 <br />