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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 /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT #,/4 w <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE / <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 <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: L4.1"Tey 6,,i-s <br /> (If Applicable) <br /> OWNER/OPERATOR: / 6 <br /> (Please Print) (Title) <br /> -- - 4 y-t <br /> (Owner/Operator Signature) (Date) <br /> ADDRESS: ,(1 go k 1136 <br /> ailing Address) <br /> 7 -, -cv Cir 3 7f� <br /> (City) (State) (Zip Code) <br /> PHONE:( ZC Cj <br /> EH 23 046 (Revised 8/3/07) <br /> 4 <br />