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SAN j f 1AQ <br /> I I I Environmental Health Department <br /> __ - -- COUNTY - <br /> AUTHORIZATION TO RELEASE <br /> * ANALYTICAL RESULTS <br /> * GEOTECHNICAL DATA <br /> * ENVIRONMENTAL / SITE ASSESSMENT INFORMATION <br /> It THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT <br /> 290 NORTH MAIN STREET MANTECA, CA 95336 <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> PRO VERA ANALYTICAL LABORATORY , INC . <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR <br /> MY REPRESENTATIVE. <br /> BUSINESS NAME : <br /> SUPER STOP GAS & LIQUOR <br /> (1f•Applicable) <br /> OWNER: MANDEEP DUA OWNER <br /> (Please P •int) (Title) <br /> 11 /29/2021 <br /> (Owner Signature) (Date) <br /> ADDRESS : <br /> 209 NORTH MAIN STREET <br /> (Mailing Address) <br /> MANTECA CA 95336 <br /> (City) (State) (Zip Code) <br /> PHONE : <br /> ( 209 ) 815-5180 <br /> 6of6 <br />