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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 /> 1,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT <br /> (Street Address) (city) <br /> HEREBY AUTHORIZE <br /> (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 /> (If Applicable) <br /> OWNER/OPERATOR: <br /> (Mease Print) <br /> (Owner/Operator Signa&�4�­ (Date) <br /> ADDRESS: 0-5 7 -1 k24 7��q I <br /> (Mailing Address) <br /> rity) (State) (Zip Code) <br /> PHONE: t-29 3�(,6 <br /> EH 23 046 (Revised 8/3/07) <br /> 4 <br />