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C <br />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 />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT ss-sQ [_te, t AD A e-� <br />(Street Address) (City) <br />HEREBY AUTHORIZE m C; 6- CC- A 1 4izt. zz c -Ac, <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 />(If Applicable) <br />(Please Print) (Title) <br />z % % �,qN(c M I-)va 6 fvsA-- 2/� I <br />(Owner/Operator Signature) (Date) <br />ADDRESS: 3 7 C' <br />(Mailing Address) <br />(City) (State) (Zip Code) <br />PHONE: (Z0? )� z z'<____ <br />EH 23 046 (Revised 10/19/98) Page 9 <br />