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Ll <br />ENVIRONMEN <br />■ L HEALTH DEPARTMENT <br />SAN JOl QUI \ 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//FACILITY <br />LOCATED AT <br />(Street Address) iry) <br />HEREBY AUTHORIZE <br />(LaboXE. <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SOON AS IT IS AVAILABLE AND ME <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTAT <br />BUSINESS NAME: <br />OWNER: <br />(Please <br />ADDRESS: <br />PHONE: <br />EH 23 046 (Revised 02/20/09) <br />(If Applicable) <br />(Title) <br />Signature) (Date) <br />(Mailing Address) <br />(City) (State) (Zip Code) <br />5 <br />