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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />(209) 468-3420 <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT 90 V16 rol /ZOR/� <br />(Street Address) (City) <br />t <br />HEREBY AUTHORIZE -5 E Jvifl ,UfIG i/T Z/9,65 <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: /So <br />(If Applicable) <br />OWNER/OPERATOR: <br />,44EA-�T FcR <br />0 wNf-'R <br />ADDRESS: <br />-1/i f"xi'�-r�tra <br />(Please Print) ,®� �,� (Title) <br />(Owner/Operator Signature) <br />(Mailing . <br />m <br />(Date) <br />/0 E"ANn elf 9 -�.S 7 7 <br />(City) (State) (Zip Code) <br />PHONE: ( 570 614-9320 <br />EH 23 046 (Revised 08/13/99) <br />Page 9 <br />0T 39tid c00 -I3 H13Id ££b£89b60Z TO:60 0002/LT/S0 <br />