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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 DATAJ a <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMA N <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PR RTY AND/OR FACILITY LOCATED AT <br /> (Street Address) 0JREBSXYUTHORIZE <br /> (City) <br /> /AVABLE <br /> Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTTION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IAND AT THE SAME TIME IT IS PROVIDED TO ME OR MY <br /> ESENTATIVE. <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 Code) <br /> PHONE: ) <br /> EH230038(revised 7-26-2016) 6 <br />