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JANn,J0 AQUIN • Envirtnental Health Department <br /> —COUNTY <br /> AUTHORIZATION TO RELEASE <br /> * ANALYTICAL RESULTS <br /> * GEOTECHNICAL DATA <br /> *ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOROFTHE PROPERTY AND/OR FACILITY LOCATED AT <br /> ( jgW-7 <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> (Laboratory) o,1bo <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 <br /> SAME TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: -10" <br /> (If Applicable) <br /> OWNER/OPERATOR: <br /> (Please Print) (Title) <br /> y (Owner/Operator Signature) (Date) <br /> ADDRESS: f— o0 Z 1 , r)k�CR.S i I -K 1 <br /> (Mailing Address) <br /> (City) (State) (Zip Code) <br /> PHONE:( ) <br /> 8of10 <br />