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12/26/2003_ 15:54 20946834 FIFTH FLOOR• PAGE 05 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />(209) 468-3420 <br />AUTHORIZATION TO RELEASE <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTALISITE ASSESS[ENT INFORMATION <br />I. THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT `3% 2 Sr �l2f4C -] & ./D •T%Z 4c `� <br />(Street Address) (Cary) <br />HEREBY AUTHORIZE <br />Ki rF A� �yTic�L <br />(Laboratory) <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: <br />(I.fAPplicable) <br />OWNER/OPERATOR: <br />S►+�u- o ��l�x is -- tbzgy ?i ku_; P►A •�-ryc <br />v (Please Print) (title) I <br />(Arpaler signature) (Date) <br />ADDRESS: 3 I y b G)�-tjGAS c� 1>W - <br />(Mailing Address) <br />►4. 5L7O CA 956-70 <br />(City) (State) (Zip Code) <br />PHONE ClL / I b 3 / - / 3 o O <br />-T <br />EH 23 046 (Revised 1/24/02) <br />6 <br />