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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone:(209) 3420 Fax: (209) 8-3433 <br /> AUTHORIZATION TO RELEASE <br /> *AN Y`E ICAL RESULTS <br /> *61-AY1'FCI INICAL DATA <br /> ' F.NVIRONMEiNTAUSITE ASSESSMENT INFORMATION <br /> I,THE,UNIMRSIGNED OWNER AND/OR OPERATOR OF TETE PROPERTY ANIXOR FACILITY <br /> LOCATED AT p <br /> (Strew Ad&ess) <br /> HEREBY <br /> 3Y <br /> AUTHORIZE <br /> a horatory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COU TY <br /> ENVIRONMENTAL HEALTH DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE S ME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: <br /> �m. <br /> _. (`If�I�liGr�ble <br /> C)1d'Nt?Rlt)PE TC)R: _ <br /> /C) tur Si nature) < t <br /> DRESS <br /> { rilita Address) <br /> 5 t <br /> (C'ity) �Staite) l7ip Code) <br /> PHONE: <br /> EEE 23 0,16 (Revi d 10/30/12) 8 <br />