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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fag: (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 THE PROPERTY AND/OR FACILITY <br />LOCATED AT ' I �Sm <br />(Street Address) ttJ (City) <br />HEREBY AUTHORIZ <br />t___/ (Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: <br />OWNER/��nTO�R: <br />(If Applicable) <br />IN <br />Print) (Title) <br />1(Owner/Operator Signature) (Date) <br />ADDRESS: / v <br />PHONE: <br />EH 23 046 (Revised 8/3/07) <br />(Mailing Address) <br />(City) (State) (Zip Code) <br />4 <br />