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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />(209) 468-3420 <br />AUTHORIZATION TO RELEASE <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />E.\'VIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />114STOCIV-70 4 <br />LOCATED AT <br />4+60 wA-rEe.Lco ego <br />Street Address) (City) <br />HEREBY AUTHORIZE SEQyojA. , 04AJ,_n-)CA, <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANTAL.YTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br />HEALTH SERVICES-ENVIRONI MENTAL 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: ckifwao f� Fri-00.K.;r_5 GD <br />(If Applicable) <br />OWNER/OPERATOR: iy_a C -416s -'b �J Cid �� i ��'�J r W -1p` <br />(Please Print) (title) <br />pwnermperator Sienature) <br />(Date) <br />ADDRESS: ?0 �O� 6 004- <br />ZXMCiJ , CA 9 7 3 <br />(Mailing Address) <br />s4AJ 44rh,0x1 <br />(City) <br />PHONE: <br />EH 23 046 (Revised 9/11/96) Page 9 <br />cf q 1q's-f -- <br />(State) (Zip Code) <br />