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SANiJOAQU IN Environmental Health Department <br />- COUNTY <br />AUTHORIZATIO TO RELEASE <br />ZGTECEMCAL <br />ICAL RESULTS <br />DATA <br />ENVIRONMENTSSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNEXAND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT <br />Address) <br />HEREBY AUTHORIZE <br />(City) <br />(Laboratory) <br />TO ASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL <br />TH DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR <br />MY REPRESENTATIVE. <br />BUSINESS NAME: <br />(If Applicable) <br />(Please Print) (Title) . <br />(Owner Signature) (Date) <br />ADDRESS: <br />(Mailing Address) <br />(City') <br />PHONE: <br />6of6 <br />(State) (Zip Code) <br />