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- � a <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3420 <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 � �' c`� 5 FF}sT FRerIa t l I Si mi . ��L`Cl� TO Iy C6 <br /> (Street Address) n (City) <br /> HEREBY AUTHORIZE �R2C ) sioi'� �nyirZ�1 %cC. <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE- <br /> BUSINESS NAME: S � (1IGO � �'9SClin � <br /> (If Applicable) <br /> OWNERIOPERATOR: CS 001rl mzl RQ T` wnE <br /> (Please Print) (Title) <br /> �of Ge <br /> (Owner/Operator Sig �7 �7) (Dare) <br /> ADDRESS : z �F q / 4sg Nrn/�1) 1� V N <br /> (Mailing Address) <br /> Sit, CK lors) R 95 ZAP <br /> (City) l ' (state) (Zip Code) <br /> PHONE: ( 'Z09 ) q1 q ^ 0y3V <br /> EH 23 046 (Revised 10/ 19/98) Page 9 <br />