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`, 'Aw ..i <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERV ICES <br />ENVIRONMENTAL HEALTH DIVISION <br />(209)468-3420 <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 <br />LOCATED AT <br />Address) <br />HEREBY AUTHORIZE <br />(City) <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 />OWNER/OPERATOR: <br />(If <br />Print) <br />t^C� <br />(Title) <br />(Owner/Operator Signature) (Date) <br />ADDRESS: 3 2 S /D f'{ <br />(Mailing Address) <br />(City) Q ' (state) <br />PHONE:( 20`1) <br />EH 23 046 (Revised 08/13/99) Page 9 <br />;5,7 b <br />