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iTKN .SER .STAT . EOUIP . CO TEL <br /> Ju ,97 25 : 22 No . 007 P .02/03 <br /> h I <br /> SAN JOAQUIN COUNTY PUBLIC HEA1 TH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3420 , <br /> AUTHORIZATION TO RELEASE <br /> * ANALYTICAL RESULTS <br /> * GEOTECHNICAL DATA' <br /> I's <br /> ENVIRONMENTAL/SITE ASSESSMENT'INFORMATION <br /> 'r <br />` 4 <br /> I h <br /> .s <br /> I� <br /> 1. THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT <br /> (Sire t res (City) <br /> HEREBY AUTHORIZE <br /> ( ar�ctory) <br /> TO RELEASE ANY ANIS ALL ANALYTICAL INFORMATION TO SAN 10AQUIN COUNTY PUBLIC <br /> HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVIS€ON AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: <br /> (If Applicable) <br /> OWNER/OPERATOR: <br /> (Please Prtat) (IFtle) <br /> (Owner/Operator ignre) ;k <br /> atu } <br /> ADDRESS: zr_ /P5",/ <br /> (Mailing <br /> A—d�dress) <br /> /4 FS727 <br /> Pry) (Stare) (Zip Code) <br /> PHONE: S-- <br /> 'k <br /> 7 <br /> 17 <br /> EH 23 046 (Revised 9111196) Page 9 <br />