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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 INTORMATION <br />1. THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT <br />(Street.Address) (City) <br />L Laharatory) 1�0 <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT TILE SAME TIME IT IS PROVIDED TO ME OR MY <br />,� 1 REPRESENTATIVE. <br />BUSINESS NAME: _ v/`0Te•V k6 svl& +l _----- -- <br />(IjApplicable) <br />lAr ��AsD ID <br />—rvnef Signalm-e) (Date) <br />ADDRESS: —"Vy ID a pit- D <br />(Mailing Address) <br />S A_ kin Cid - C1521 S <br />(City) (State) (Zip Code) <br />PHONE: <br />J� tt 4 t <br />J <br />`G2 <br />y <br />( <br />APP 018 <br />ENIVf 0',! ,11ENTAL _ <br />EH230036 (revised 12-11-15) 6 1 f14-:, %.€ iT1�iYN } <br />