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OCT-25-2010 22:16 From: <br /> To:4683433 Pase:12�12 <br /> 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 /> : ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> 1,THE UNDERSIGNED OWNER AND/OR OPERATOR OF I HF.PROPLRTY AND/OR FACILITY LOCATED AT <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR MY <br /> REPRESENTATIVE, <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:( 1 <br /> EH 23 046 (Revised 07/21/10) <br /> 6 <br />