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SAN JOAIN COUNTY PUBLIC HEALTH SER479L <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209)'468-3420 <br /> AUTHORIZATION TO RELEASE <br /> • ANALYTICAL RESULTS <br /> ' GEOTECHMCAL DATA <br /> ' ENwRONMENTAusrm ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT /' 5110 Pacific Ave Stockton CA 95207 <br /> / (Street Address) Ply)_. <br /> HEREBY AUTHORIZE Groundwater Technology <br /> (Laboratory or Consultant) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE <br /> 'Sears Roebuck & Co. <br /> BUSINESS NAME: <br /> .� T ,(IfApplirable� <br /> �. <br /> Same as above e���.(�c � <br /> r "O WNER/OPERATOR: _ _ <br /> f <br /> (Please Print)! --(Tale) w <br /> (Owner/Uperator SigsiaCute) - <br /> :ADDkf_iS:_ ' 2100 N Tustin <br /> " - - - - (Mailing Addrrmt) <br /> Orange, CA 92665 _ <br /> (City) _ f (stare) u (Zip Code) <br /> 'xHHONE• ( 209 1477-8111 (local number) <br /> J' <br /> A/9 <br /> EH 23 041 (Revised 7-10-92) PBe 9 <br />