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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <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 77 00 Mm*GCQ yd ea�l'i✓'t IJ'�OG�;�,O►'1 CJ� <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE ` L <br /> J (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 TIME IT IS PROVIDED TOME OR MY <br /> REPRESENTATIVE. <br /> BUSINESS NAME: l l hG t t <br /> (If Applicable) n � <br /> OWNER/OPERATOR: �1 611 PAOG�UG f 11� pro i tai, A441A44nr <br /> (Please Print) (Title) <br /> (Owner/Operator Signatrace (Date) <br /> ADDRESS: f-/Z(/ gtF� 5)1oGk to 6Y114(. 5 25-6- 32—/ <br /> (Mailing Address) <br /> 6=19 C^oyc, <br /> d (City) (State) (Zip Code) <br /> PHONE: -l(_l�) ��4(- <br /> EH 23 046 (Revised 10/16/03) Page 9 <br />