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0 ' <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />(209) 468-3420 <br />FEW 9 Tel � � <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 />(Street Address) (City) <br />HEREBY AUTHORIZE 5EQUOIA AAjA4YrjCAt_S <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: miso /A/c <br />(If Applicable) <br />A4 MT FoR O UIFJt <br />OWNER/OPERATOR: <br />1SN14xj 161 c' l PeRNIr j6xPeD1 ro <br />(Please Print) _�. ® (Title) <br />(Owner/Operator Signature) <br />ADDRESS: 2600 WIZ -41,41.1s '5T. <br />(Mailing Address) <br />(Date) <br />SOMIM <br />(City) (State) (Zip Code) <br />PHONE: (5/0 ) ® � <br />EH 23 046 (Revised 08/13/99) Page 9 <br />