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:• ,09/09/2009 WED 11204 PAX 683433 SJC EHD -»- Stockton Sery S*Q Cc 2007/008 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> AUTHORIZATION TO RELE SE <br /> •ANALYTICAL RESULTS <br /> •GEOTECHNICAL DATA <br /> • ENVIRO ENTAL/SITE ASSESSMENT IN ORMATION <br /> 1,THE ERS NED OWNER AND/O OPE TOR OF THE PROPER Y AND/OR FACILITY <br /> LOCATE AT <br /> (Street Address) (Cin,) <br /> HEREBY AU i RIZE <br /> (Laboratory) <br /> TO RELEASE A ND ALL ANALYTI AL INFORMATION OS 30AQUIN COU Y ENVIRONMENTAL HEALTH <br /> DEPARTMENT S ON AS 1T IS AVAI BLE AND AT TH SA E <br /> TIME IT IS PRO IDE D 0 ME OR MY PRESENTATIV <br /> BUSINESS NA E: <br /> (1 pp/icabl) <br /> OWNER: <br /> (Please Print) (Title) <br /> (Owner Signature) (Date) <br /> ADDRESS: <br /> (Mailing ddress) --- <br /> (City) (State) (Zip Code) <br /> PHONE: <br /> EH 23 046 (Revised 02/20/09) <br /> 5 <br />