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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <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 <br />330`f ?j � 144mr►er (yank , S filet <br />(Street Address) (City) <br />HEREBY AUTHORIZE <br />!o-�4.s 2v'7 <br />(Laboratory) <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 <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: 6-* S .S -,t3 `4 e , <br />(If Applicable) <br />X OWNER/OPERATOR: <br />x <br />(Title) <br />�.( fUy1lL•S%2.. <br />A <br />K\__()Pwft'r/Operator Signature) (Date) <br />/ <br />ADDRESS: �, 3J C� �'i W% wk <br />(Mailing Address) <br />(City) (State) (Zip Code) <br />PHONE: ( ) 9 C Z . � 4-1// <br />EH 23 046 (Revised 8/3/07) <br />4 <br />