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JOAQUIN COUNTY PUBLIC HEAL RVICES�� " <br />ENVIRONMENTAL HEALTH DIVISION <br />(209) 468-3420 <br />AUTHORIZATION TO RELEASE <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 ({�J O S, O L I V E /4 V E <br />(Street Address) (City) <br />HEREBY AUTHORIZE CLS CA, 65 <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: P jt k 5 -top MPrfZ ILLS I^l� <br />(If Applicable) <br />OWNER/OPERATOR: <br />L6 -E <br />(Owner/Operator Signature) (Date) <br />ADDRESS: e"W-rEV-1215Er 57 <br />(Mailing Address) <br />Iv1Ar✓�K� <br />F2eMowr C14 c745 -3S <br />(City) (State) (T.cp Code) <br />PHONE:( S -/c> ) 6'S7 — S5a <br />Osmer Signature tate <br />EH 23 046 (Revised 7/10/96) Page 9 <br />