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a <br /> ENVIRONMENTAL <br /> SAN JAUIN COUNTY <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> AUTHORIZATION TO RELEASE <br /> *ANALYTICAL RESULTS <br /> *GEOTECHNICAL DATA <br /> 8 <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT <br /> 3032 WATERLOO RD, STOCKTON <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> (Labo <br /> ratory) <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 TIME IT IS PROVIDED TO ME OR MY <br /> REPRESENTATIVE. <br /> BUSINESS NAME: WATERLOO FOOD&FUEL <br /> (IfA*licable) <br /> OWNER OPERATOR <br /> OWNER: PRITPA S C IJLLS�IY <br /> (Please Print) (Title) <br /> (Owner S:,?nature) (Date) <br /> ADDRESS: 3032 WATERLOO RD <br /> 0 <br /> (Mailing Address) <br /> STOCKTON CA 95205 <br /> (City) (State) (Zip Code) <br /> PHONE:( 916 865-8616 <br /> EH 23 046 (Revised 07/21/10) <br /> a <br /> 6 <br />