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0 9 0 a <br />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 INFORMA <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY A /OR FACILITY <br />LOCATED AT <br />(Street Address) (City) <br />HEREBY AUTHORIZE <br />(Lab/ATHE <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMSAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SOON AS IT IS AVAILABLE ANDAME <br />TIME IT IS PROVIDED TOME OR MY REPRESENTA <br />BUSINESS NAME: <br />OWNER: <br />(lf .-I pplicable) <br />(Please Pri t) (Title) <br />(Ow r Signature) (Date) <br />ADDRESS: <br />(14ailing Address) <br />(City) <br />PHONE: (�) <br />EH 23 046 (Revised 02/20/09) <br />5 <br />(Stale) (7ip Code) <br />