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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 /> P Arct:. -4 602-o 1' 11 YOSQm i-c-- AV. AO-A+eC0- C <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> Te s+ Amer ; c a Lc-bora-t-a r y (� q b ( Q e r o--&o--& A�e.,-,.,e_ <br /> R4.9 � 2(01 — (42Z koo S.rV�Ac ) (f- A <br /> (Laboratory) 9 L (c <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 /> BUSINESS NAME: 1�'f�`�`�� +� a� f)C \ ►��2 \) <br /> (If Applicable) <br /> OWNER/OPERATOR: <br /> 3P WQs-� Loose ��oa� �ts, c . �. c �^ v. w� � <br /> I/ ^ (Please Print) (Title) Eric. '(V. &J o n-t' e-8c�- 10 PVA.% . <br /> - 08 <br /> (Owner/Operator Signature) (Date) <br /> ADDRESS. �- 0 �oX !Z�) 0 t S <br /> (Mailing Address) <br /> C N 9062-2— <br /> (City) (State) (Zip Code) <br /> PHONE:( S t C ) y 3 a - �3 9 �- <br /> EH 23 046 (Revised 8/3/07) <br /> 4 <br />