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i <br /> ENVIRONMENTAL HEALTHE T NT I <br /> SAN JOAQUIN COUNTY <br /> Telephone:(209)468-3420 Fax:(209)468-3433 <br /> I <br /> AUTHORIZATION TO RELEASE <br /> *ANALYTICAL RESULTS j <br /> *GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION ; I <br /> 1,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 292-4 W WM RVV-Tats 'Tytr�C. 5�hCKTn N <br /> (Street Address) (City) <br /> HEREBY SvA 1,X$,(—, (�S <br /> AUTHORIZE �a- <br /> (Laboratory) <br /> 4 <br /> i <br /> TO RELEASE ANY AND ALL ANALYTICAL, INFORMATION TO SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. y I <br /> BUSINESS NAME: <br /> tYN SAwAvimeTt E Tum <br /> (Y.4pplicable) ----- <br /> OWNER/OPERATOR: Jr-(=r- S`pwh(/IAFrrp I~ <br /> (please print) (1 ilJe) <br /> i <br /> (Owner/Operator Sige rr e) (Date) <br /> i <br /> ADDRESS: ► t rpt 6,*a,,j c $' <br /> (AlatlingAddress) <br /> (City) (Slate) (lip Code) <br /> PHONE:( ? - t; ,Ot ct <br /> i <br /> t <br /> i <br /> EH 23 046 (Revised 811/11) 8 <br />