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0 0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone- (209) 468-3420 Fax- (209) 468-3433 <br />9 <br />* ANALYTICAL RESULTS <br />* oEoTECHNICAL. DATA. <br />FNVIR,ONMENTAL/SITT, ASSESSMENT INFORMATION <br />1, THE UNDERSIGNED OWNER AND/OR OPEFLATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT <br />---6 L <br />Address) <br />7s.5) <br />HEREBY AUTHORIZE <br />(.Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SOON AS ITIS AVAILABLE AND AT THE SAME <br />TIME IT IS PROVIDFD TO Mr OR MY RF[IRESENTATIVE, <br />BUSINESS NAME' (If Applicable) <br />OWNER: <br />(!'lease Print) .- (Title) <br />(Owner Signature) (b171e) <br />ADDR8S,S'-, <br />(mailing Address) <br />(city) P (State) (Zip Code) <br />PHONE- (--), . --.- <br />EH 23 046 (Rcviscd 02/20/09) <br />5 <br />