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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 />• ENVIRONMENTAUSITE ASSESSMENT INFORMATION <br />1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT <br />LAM, w4ty boO 9oAD S�c"b') <br />(Street Address) (Cit) <br />Y AUTH <br />I'L441<tv" - ML 2ovyavv,,j ('A <br />Laboratory) qO�_ GG",0 L� U <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: <br />VjO eV IM she,U <br />WI <br />y-, <br />`-t-Zlo-tB <br />Signature) (Date) <br />ADDRESS: L43 y E wC,, �y l D Q <br />(Mailing Address) <br />SlKk,:�n C+q- ci5215 - <br />"— (City) (State) (Zip Code) <br />PHONE: 2( Oak <br />EH23003$ (revised 12-11-15) <br />RECEIVED <br />APR 2 72018 <br />ENVIRONMENTAL <br />HEATH DEPARTMENT <br />