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SA JOAQ UIN COUNTY PUBLIC HEALTH SE. VICES <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 />LOCATED AT agqQ VI C 7"ee ROAL2 O/ <br />(Street Address) (City) <br />HEREBY AUTHORIZE _5 E 0 ®f A AAAA L X j- j G e_ L <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 />Applicable) <br />A4,60 -r -O OtJ Pt <br />OWNER/OPERATOR: S,,q <br />(Blease Prim (Title) <br />(Owner/Operator Signature) <br />ADDRESS: 0 I Z - L 1 A /iS C. <br />(Mailing Address) <br />2 <br />(Date) <br />(City) (State) (Zip Code) <br />PHONE: (3-10 ) CQ ! m j93 g <br />EH 23 046 (Revised 08/13/99) Page 9 <br />