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ENVIRONMENTAL HEALTH <br /> SAN JAUIN 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 OPERATOR OF THE PROPERTY AND/ FACILITY <br /> LOCATED AT <br /> (Street A ess) ' City) <br /> HEREBY AUTHORIZE <br /> aboratory) <br /> TO RELEASE ANY AND ALL ANALYTI L INFO ATI HE O SSAEN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON A IT IS AVAIL BLE AND <br /> TIME IT IS PROVIDED TO ME MY REP SENT IVE. <br /> BUSINESS NAME: (If Applicable) <br /> OWNER: <br /> (Plea a Print) (Title) <br /> (Owner Signature) (Date) <br /> ADDRESS: <br /> (Mailing Address) <br /> (City) (State) (Zip Code) <br /> PHONE: <br /> EH 2 046 (Revised 02/20/09) <br /> 5 <br />