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SA OAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />(209) 468-3420 <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 />(Street Address) (City) <br />HEREBY AUTHORIZE ; v r <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br />HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: tri r✓c'i ;7 < i T'/% g'-- TApplicable) <br />OWNER/OPERATOR <br />1'�lq b <br />(Please Print) <br />(Owner/Operator Signature) <br />("Title) <br />ADDRESS: <br />(Mailing Address) <br />(City) (State) (Zip Code) <br />PHONE: <br />EH 23 046 (Revised 08/13/99) Page 9 <br />U <br />11 <br />11 <br />