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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <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 L <br /> LOCATED AT p lA!c b } 6 Q 2-0 I- � � I Q SQ V►� ti v. 9 !::" l e C0. �C <br /> / (Street Address) (City) ���r L <br /> Te s+ Amer; ca Ga-bor'o.:ta r (� `f 6 � 0Qr'o^ <br /> HEREBY AUTHORIZE / 2 Z2. 5.; �L `p p .=r v v�e. l L A <br /> a�F9 c� 1 — (4 <br /> (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 <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> p ( C O✓�'�(D-L'�O r- <br /> 13USINE <br /> SSNAME: [atad.��o l�ecv��Lo-� �iNC \ PV2nd <br /> (If Applicable) <br /> 0�p n ti-� For J <br /> (�Q w Q g-� L c o-s � i(c e\w CA S� . L. C V. <br /> (Please Print) (Tale) E r i c- V• <br /> (Owner/Operator Signature) (Date) <br /> ADDRESS: �. O �Ox e© lS <br /> (Mailing Address) <br /> Q.Ije-A . ACL � C <br /> (City) (State) (Zip Code) <br /> PHONE: <br /> EH 23 046 (Revised 8/3/07) <br /> 4 <br />