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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <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) <br />HEREBY AUTHORIZE <br />(city) <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SOON AS 117 IS AVAILABLE AND AT THE SAME <br />TME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: <br />OWNER/OPERATOR <br />(If Applicable) <br />(Please Print) (Title) <br />(Owner/Operator Signature) (Date) <br />EH 23 046 (Revised 8/4/06) <br />(Mailing Address) <br />(City) (State) (Zip Code) <br />5! <br />