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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 /> 15 THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT <br /> (Slreel Address) (Lib) <br /> HEREBY AUTHORIZE <br /> (LoboralorJ) <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 'TIME IT IS PROVIDED TO ME OR MY <br /> REPRESENTATIVE. <br /> BUSINESS NAME: <br /> (lfylpplicable) <br /> OWNER: <br /> (Please Print) (111Ue) <br /> (Owner signalure) (Dale) <br /> ADDRESS: <br /> (,Mailing Address) <br /> (Cit}) (stale) (Zip Code) <br /> PHONE: ( ) <br /> i <br /> EH230038 (revised 12-11 -15) 6 <br />