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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 />GFO'IT-.CfINICA[, DATA <br />ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />U� <br />NIf,k[E <br />L)ERSID OWNER AND/OR OPER�TCIR OF THE PROPERTY AND/0/1-ACILITY LOCATED AT <br />'- , - -\ _ I <br />HEREBY Aix TH0RZE <br />raforjq <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JO QUIN COUNTY f-,NVIRONN,,IENTAI, HEALTH <br />DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SA ETIME ITIS PROVIDED TOMEORMY <br />REPRESENTATIVE. <br />'31 <br />-,SINESS NAME: <br />(If 4PV/lCabW <br />OWNER:—,*— <br />(Please P int) (Tilde) <br />-'- j <br />(Owne Signature oa <br />ADDRESS: <br />(1falling A ss <br />("State) <br />PHONE: ( '- <br />EH 23 046 <br />-EH23046 (Revised 07/17/14) <br />A <br />