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0 9 <br />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 z - <br />(Street <br />Address) <br />HEREBY AUTHORIZE <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMAT <br />DEPARTMENT AS SOON AS IT IS AVAILA/BI,� <br />__ <br />TIME IT IS PROVIDED TO ME OR MY REP ESENTATIN <br />BUSINESS NAME: (If <br />OWNER: <br />(Please Print) <br />(Owner <br />ADDRESS: <br />(Mailing Address) <br />(City) <br />PHONE: <br />EH 23 046 (Revi�d 02/20/09) <br />(Date) <br />5 <br />COUNTY ENVIRONMENTAL HEALTH <br />(Title) <br />(State) (Zip Code) <br />