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FUST OIL -- <br />SAN JOAQULN COUNTY PUBLIC HEALTH SERVICES <br />EWIROMENTAL fIEALTHH DIVISION <br />N <br />! (209) 469-3420 <br />AU MORI ATION TO RELEASE <br />( f • ANALYTICAL RESULTS <br />• CEOTECI-INICAL DATA. <br />i <br />" ENVIRONMF—NTALZFM ASSESSMENT INFORMATION <br />f � i <br />i <br />I, T�i>~ UNDERSIGNED <br />LOCATED AT C) 1 -12 - <br />WI, <br />AND/OR OPERATOR OF THE PROPERTY A.*iD/OR FACILITY <br />HEREBY AUTHORIZE (���� <br />j <br />TO REL.E.A,SE ANY AND ALL ANAL, <br />? I <br />14EALTH SERVICES AS SOON AS IT <br />TO ME OR MY 'REPRESENTATIVE, <br />YIiCAL <br />I <br />{City) <br />ME <br />LLaborp4wy or C.onsu&ar1) �.. <br />INFORMATION TO SAN JOAQUIN COUNr'TY PUBLIC <br />iS AVAILABLEAND AT THE SAME TIME IT IS PROVIDED <br />I <br />i <br />i <br />BUSINI=SS�NAM FE- _Ylj (, �� i7 I <br />I I (lfApptccoble) <br />O WNE WC <br />061 <br />+ (Cio ! (St .re) (Zip Code) <br />PHONE: Ji <br />! <br />1 , <br />DATE: I j <br />EH 23 041 (Re.nscd 9.10-92) Page 9 <br />