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E <br />EEI <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />AUTHORIZATION TO RELEASE y <br />., 4 <br />C V <br />4tlr d R#§{iC'a�' <br />* ANALYTICAL RESULTS J A N 2018 <br />* GEOTECHNICAL DATA N <br />* ENVIRONMENTAUSITE ASSESSMENT INFORMATION Via' 3 j 'T <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY 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 TIME IT IS PROVIDED TO ME OR MY <br />REPRESENTATIVE. <br />BUSINESS NAME: <br />ADDRESS: <br />PHONE: <br />(If Applicable) <br />(Please Print) <br />(Owner Signature) <br />(Mailing Address) <br />(City) <br />EH230038 (revised 7-26-2016) 6 <br />(Title) <br />(Date) <br />(State) (Zip Code) <br />