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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 DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATI OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT <br />(Street Address) <br />HEREBY AUTHORIZE <br />TO RELEASE <br />DEPARTMEN <br />TIME IT IS PF <br />BUSINESS NAME: <br />OWNER: <br />ADDRESS: <br />D ALL ANALY" <br />DN AS IT IS AV, <br />TO ME OR MY <br />'ORMATION TO SAN <br />AND At THE SAME <br />;NTATI E. <br />(Lf <br />Print) (Title) <br />Signature) ( ate) <br />(Mailing Address) <br />IN COUNTY ENVIRONMENTAL HEALTH <br />(City) (State) (Zip Code) <br />PHONE: ( ) <br />EH 23 046 (Revised 02/20/09) <br />5 <br />