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• 09/09/2009 WED 11:04 FAX 94683433 SJC EHD --- Stockton Sery S4- Eq Co <br />ENVIRONMENTAL HEALTH uumAEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />AUTHORIZATION TO RELEASE <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTALJSITE ASSESSMENT IN. <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY <br />LOCATED AT <br />�(Sfreet,4ddress) <br />HEREBY AUTHORIZE <br />TO RELEASE ANY ND LL ANALYTICAL INFRMATION TO SAN <br />DEPARTMENT AS S AS IT IS AVAILABLE A D AT THE SAME <br />TIME IT IS PROVIDED T ME OR MY REPRESEN ATIVE. <br />BUSINESS NAME: <br />OWNER: <br />Print) <br />(fl <br />TION <br />FACILITY <br />0007/008 <br />COUNTY ENVIRONMENTAL HEALTH <br />(O ' ner Signature) (Date) <br />ADDRESS: <br />(Mailing Address) <br />(City) (State (Zip C ) <br />PHONE: �_) <br />EH 23 046 (Revised 02/20/09) <br />