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ENVIRONMENTAL HEALTH DEPART NT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 468-3420 Fax: (209)468-3433 <br /> AUTHORIZATION TO RELEAS <br /> *ANALYTICAL RESULTS <br /> * GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT FORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE P PERTY AND/OR FACILITY <br /> 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 <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: <br /> (If<4pplicafile) <br /> OWNER/OPERATOR: <br /> (Please Print) (Title) <br /> ((honer/Operator Signature) (Date) <br /> ADDRESS: <br /> (flailing Address) <br /> (009 (State) (Zip Code) <br /> PHONE:( ) <br /> 6r <br /> EH 23 046 (Revised 8/3/07) <br /> 4 <br />