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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 <br /> LOCATED AT <br /> 13P (.ozo AV. . <br /> (Street Address) (City) <br /> Te s+ YY\Qf \ C0. La-b o(o...•ta r y 1 `f b ()o- r%o-n <br /> HEREBY AUTHORIZE 1+9 / 2-6 1 - f,0 2.2- 5. te— too S ry i^e- <br /> C <br /> (Laboratory) 92- <br /> TO <br /> 2-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 /> T3USINESS NAME. <br /> Qato�.�g_o �eclno.v�iLo-� 3~�1C . \ ►`� 2nd <br /> (If Applicable) <br /> V•�9n�-� ForOWNER/OPERATOR: J <br /> R q w Q-si Loos �r o a., �.t s� c. • • c �- v. v� o- <br /> (Please Print) (Title) E r) V IN1 o n•t S G" P Yn, <br /> 1.20 0. 0 MOinte_A& (►1O+�a el' ���� DB <br /> (Owner/Operator Signature) Date) <br /> ADDRESS: �• Qox !�;0 L S <br /> (� (Mailing Address) <br /> (City) (Stale) (Zip Code) <br /> PHONE:( S l O ) W3 a 13 9 T <br /> EH 23 046 (Revised 8/3/07) <br /> 4 <br />