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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN <br />COUNTY <br />Telephone: I' { (209) 468-3433 <br />111 1114 910 NEW <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 LOCATED AT <br />(Street Address) <br />(City) <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL <br />HEALTH DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR MY <br />REPRESENTATIVE. <br />11.11 `II�ix.Y3 <br />(If Applicable) <br />OWNER: <br />(Please Print) (Title) <br />(Owner Signature) (Date) <br />(Mailing Address) <br />(City) (State) (Zip Code) <br />EH 23 046 (Revised 07/21/10) <br />