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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3420 <br /> i <br /> AUTHORIZATION TO RELEASE <br /> F <br /> r * ANALYTICAL RESULTS <br /> " GEOTECHNICAL DATA <br /> * ENVIRONNiENTAUSITE ASSESSMENT INFORMATION <br /> F <br /> �~ I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACTUTY <br /> LOCATED AT � o j Sa�t� �-fh c olcn T . Stac�+�Y1 <br /> I(Street Adrl�s � ! ((City} L� b <br /> HEREBY AUTHORIZE ISI a Y lk S eC <br /> i NV ty a v1iMci� ra <br /> _. (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL. INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES-F-fVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> F TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> I BUSINESS NAME. <br /> (If Applicable) <br /> OWNER/OPERATOR: Ic-"—V of olss o a W hcw- _- -- <br /> (Please Print) (merle) <br /> q/Z7191 <br /> ' Owner/Operator Signature) (Dare) <br /> ADDRESS: 114 5 iv . c"✓tw W� <br /> (MailingAddress) <br /> StaG��h cA 15 2-C7 t.p <br /> (City) (Stare) (Zip Cade) <br /> PHONE: ( Z�GJ ) to (� 5 Iq 2- <br /> r <br /> EH 23 046 (Revised 10/19/98) Page 9 <br />