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NIA ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> AUTHORIZATION TO RELEASE <br /> * ANALYTICAL RESULTS <br /> * GEOTECHNICAL DATA <br /> %ENVIR ENTAL/SITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/ OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT <br /> (Street Address) (City) <br /> HERE Y AUTHORIZE <br /> (Cabo <br /> rata <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO N JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON A5 IT IS AVAILABLE AND AT TH SAME TIME IT IS PROVIDED TO ME OR MY <br /> REPRESENTATIV <br /> BUSINESS NAME: <br /> (If Applicable) <br /> OWNER: <br /> (Please Print) (Title) <br /> (Owner Signature) (Date) <br /> ADDRESS: <br /> (Mailing Address) <br /> (City) (State) (Zip C e) <br /> PHONE: ( } <br /> EH 23 046 (Revised 07/21/10) <br /> 6 <br />