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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 <br />NERAND//OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT g6)9 <br />P) - IA (d (3 4't <br />(Street'A'ddress) (City) <br />HEREBY <br />AUTHORIZE <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH 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 Applicable) <br />(City) 40-111/f <br />— (State) (Zip Code) <br />PHONE: ( Aq ) jf 0— 1L� 11t <br />EH 23 046 (Revised 07/22/10) 8 <br />