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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 />• ENVIRONMENTAIJSITE ASSESSMENT INFORMATION <br />1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT <br />(Street Address) (City) <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SOON AS TT IS AVAILABLE AND AT THE SAME TIME. IT IS PROVIDED TO ME OR MY <br />t REPRESENTATIVE. <br />•` <br />BUSINESS NAME: " �v koo Gy)fA _ <br />(If Applicable) <br />OWNER: <br />).Yvi AAA �iAD <br />(7itle) <br />`A-2to-a <br />wnel Signature) (Date) <br />ADDRESS: y 3 l E Lv V~ V l Q a PVft D <br />(Mailing Address) <br />S <br />PHONE: <br />G521S <br />(City) (State) (Lip Code) <br />RECEIVED <br />4VA 8 u 18 <br />EM230038 (revised 12.11-15) 6 <br />ENV'IRQMMENTAL <br />jAEALTH DEPARTMENT <br />