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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DMSION <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 `(� E, i� SZ j� AZ E LZU 0 1 l U�, Y Z 0 N LN g 5 V 5 <br />(Street Address) (City) <br />HEREBY AUTHORIZE -N EUL M tl� 4 C ATL <br />(Laborafory) <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: <br />(if <br />OWNER/OPERATOR: �jj L\ K %\ C— L\\W_ \L EN La Q) EEjs <br />(Please Print) (Title) <br />..__...... <br />(Owner/Operator Signature) (Date) <br />ADDRESS: SAS,\ "S(01.,cJV\ 11 C®Um 7T_L.I C 1c1 2\�5 <br />(Mailing Address) <br />LA \ () S,7 U C�L,:j oR\ U� 5 <br />(City) (State) (Zip Cade) <br />PHONE: - 3 0 2 2 <br />EH 23 046 (Revised 10/19/98) Page 9 <br />