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09/09/2009 WED 11: 04 FAX 2094683433 SJC END — Stockton Sery Sta Eq Co 2007/008 <br /> �..� tir <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> AUTI-IO ZATION TO RELEASE <br /> *A ALYTICAL RESULTS <br /> *0 TECHNICAL DATA <br /> * ENVIRONMENTAUS[ ASSESSMENT MrRRMATION <br /> 1,THE UNDERSIGNED OWNE AND/OR OPERATOR OF HE PROPERTY /OR FA IT <br /> LOCATED AT <br /> (Street Add s) (City) <br /> H AUTHORIZE <br /> (Laboratory) <br /> TO REL SE ANY D ALL ANALYTICA INFORMATION TO S JOAQUIN U TY ENVIRONMENTAL HEALTH <br /> DEPAR ENT AS SO AS IT IS AVAILA E AND AT THE SAM <br /> TIMEITI ROVIDEDTO ORMYREPRE NTATIVE. <br /> BUSINESS NA <br /> ().LAPP aGle) <br /> OWNER: 1-4 <br /> Please Print) (Title) <br /> (O er Signa+ure) (Date) <br /> ADDRESS: <br /> ailing Address) <br /> (City) (State) (Lip Code) <br /> PHONE: <br /> EH 23 046 (Revised 02/20/09) <br /> 5 <br />