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SANJ O A Q U I N Environmental Health Department <br /> CUUNTY - <br /> AUTHORIZATION TO RELEASE <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 LOCATED AT <br /> ©Cl( O AI 4! 4! PSs'ao ,3 <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> 7rzOers' <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE <br /> SAME TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE . <br /> BUSINESS NAME : � —L�����f� 1 .? f'f/ zy <br /> (If Applicable) �— <br /> OWNER/OPERATOR: tel✓ <br /> (Please Print) (Title) 000r <br /> Z <br /> /(Owner/Operator Signature) (Date) <br /> ADDRESS : ? y X50 2,9 iErow co e-fA <br /> (Mailing Address) <br /> (City) /+ /(State) (Zip Code) <br /> PHONE: '� (O �� 6145 O <br /> 8of10 <br />