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ENVIR01%ri TAL HEALTH RPARTMENT <br />SAN JOAQUIN COUNTY <br />AUTHORIZATION TO RELEASE <br />ANALYTICAL RESULTS <br />-GEOTECHNICAL DATA <br />ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />TE TaR OF TI -IE <br />DERSSIGNTED OWIJER ANaff-)R OPER/A <br />FACILITY LOCATED AT <br />(Street Address) <br />rmREBY AU —FdORIZ , <br />(Laboratory) / <br />TO RELEASE ANY AND ALL ANALYTICAL INFO RMATION FTSAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />T <br />DEPARTMENT AS SOON AS IT IS AVAILABLE AND A THE SAME TIME IT IS PROVIDED TOME OR MY <br />Al <br />REPRESET� ATIVE. <br />BUSINESS NAME, <br />(YA licabk) <br />OWNER; <br />-�(6Ht3 <br />(Please Print) (Title) <br />X <br />Z(Owner Signatur rDate)f f <br />ADDRESS: <br />(Mailing Address) <br />(City) (State) (Zip Code) <br />PHONE:( <br />E14 23 046 (Revised 07/17/14) <br />6 <br />