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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY RECEIVED <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> AUTHORIZATION TO RELEASE MAR 0 2 2016 <br /> ENVIRON TAL <br /> * ANALYTICAL RESULTS H.FA!Tu nCoeQTaAchl - <br /> *GEOTECHNICAL DATA <br /> * ENVIRONMENTAUSITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED <br /> (Street Address) (City) <br /> Tl t✓171 c©asae>-�-7T 7-6> les7-rlIZ �8�� s.�-r��CFs �k3/) 4426-5 <br /> HEREBY -�-� <br /> AUTHORIZE /6J/�l��ilf <br /> (Lab4m16 y) /111,1rITYSC,4. 95°35 51071263525,' <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: <br /> (.f Applicable) <br /> OWNER/OPERATOR: �V/74/1)o <br /> (Ple int) (Title) <br /> (Ow r/Oper for lure) / (Date) <br /> ADDRESS: <br /> (Mailing Address) <br /> (City) 7 (State) (Zip Code) <br /> PHONE: (.21)!7 5y� <br /> EH 23 046 (Revised 12/10/2015) 8 <br />