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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: () Fax: () 343 <br />AUTHORIZATIONLEASE <br />ANALYTICAL RESULTS <br />' <br />GEOTECHNICAL DATA <br />ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY /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 ENVIRONM[ENTAL HEALTH <br />DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br />TIMEE IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS N . <br />(If Applicable) <br />OWNER: <br />(Please Print) (Title) <br />(Owner Signature) (Date) <br />EH 23 046 (Revised 02/20/09) <br />(City) (State) (Zip Code) <br />61 <br />