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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> (209)468-3420 <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 (o I DU :N2CiS?�. 4U6k%gkj 99 STot.k:rpm <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> $F-Qt401 A A04hWfL1 IAL <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: Am-0 Fp ai L-T) o v 5 9 S <br /> (If Applicable) <br /> OWNER/OPERATOR: QP WErr c.awcz Poeoaut-as L.L<- A4tAT Toe o%..jmtz <br /> (Please Print) <br /> PilleasePrint)A (Title) <br /> (Owner/Operator Signature) (Date) <br /> ADDRESS: 4 ( i4TZ2P d 1�.nt D2%V i <br /> (Mailing Address) <br /> Lm, PALmk (—N 5bC23 • (off, <br /> (City) (State) (Zip Code) <br /> PHONE:(-71 Lt ) L7 b - u b L) <br /> EH 23 046 (Revised 10/16/03) Page 9 <br />