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St... JOAQUIN COUNTY PUBLIC HEALTH Sb.. ✓ICES <br />ENVIRONMENTAL HEALTH DIVISION <br />(209)468-3420 <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 />CpYN SPA `s G�s P+ v4A54 <br />LOCATED AT {O�-Z N • -i-Wt 47 ��• 'I �i7G � ► G� � S'2-O•� <br />(Street Address) (City) <br />HEREBY AUTHORIZE eBeG V 01 A LtkPr,, <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br />HEALTH SERVICES -ENVIRONMENTAL 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: <br />OWNER/OPERATOR: <br />CA �A e ip^ *S CykP, :-4 A s 4 <br />(If Applicable) <br />'P� CJS O % I_ C it C)VA r-1 Fc fz_ / a <br />1153(4 %i _ A_u11-r (GL-- er-: <br />(Mailing Address) <br />(City) (State) (Zip Code) <br />PHONE: ( aZf) ) e t Ca3 <br />EH 23 046 (Revised 08/13/99) Page 9 <br />