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'/16/2005 09:01 2094 33 , EHD <br />SAN JOA.QUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />(209)466.3420 <br />i �• <br />ANALYTICAL RrsULTS <br />GEOTECHNICAL DATA <br />• ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF TFIL` PROPERTY AND/OR FACILITY <br />LOCATED AT <br />(Sttsst Address) (Cfry) <br />HEREBY AUTHORIZE <br />TO RELEASE ANY AND ALL ANALY <br />DEPARTMENT AS SOON AS IT IS AV <br />TIME IT IS PROVIDED TO ME OR%IY <br />BUSINESS NAME; <br />0 W NER/OPERATOR <br />PAGE 07 <br />INFOPMATIONTo SAN JOAQUIN COUNTY. ENVIRONMENTAL HEALTH <br />LI{1(►ND AT THE SAME <br />(OwnerlOperalor Signarure) (Date) <br />ADDRESS: <br />(Mailing Address) <br />(City) <br />PHONE: <br />FH 23 046 (Revised 1/24/02) <br />(State) <br />6' <br />