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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 INFORMATION <br />I, 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 IT IS AVAILABLE AND AT THE SAME <br />TIME 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 />ADDRESS: <br />(Mailing Address) <br />(City) <br />(State) <br />(Zip Code) <br />PHONE: (w..,. <br />EH, 23 046 (Revised 8/3/07) <br />W.j^a4 �i'�ACx�k�� .� 'tf � Nu�4..�--P'i+.WN f �.° § <br />. "�'t � I� 2@ .'4�' � 4` -0yr� faAla• y, b�, <br />k y g� SM�'.i"U <br />Sw u4.[ ^1-. {,,... <br />kt9' � ,'n. '. 9' <br />d .k,b 7 w9 <br />y1�fF� �l*"4"�w.' �y <br />'�." J^ "M # $I+ A - s•W $'. A ♦,T, <br />a�' <br />i ^aF" Y °5. r1. F'E 4 vMe <br />212 <br />