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SANVit, O A Q U IN Environmental Health Department <br />-----COUNTY— <br />AUTHORIZATIO TO RELEASE <br />/ANAL CAL RESULTS <br />NICAL DATA <br />ENVIRONMENTSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNE AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT <br />(St et Address) (City) <br />HEREBY AUTHORIZE <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 />OWNER: <br />(Please Print) (Title) <br />(Owner Signature) (Date) <br />ADDRESS: <br />(Mailing Address) <br />(City) (State) (Zip Code) <br />PHONE: <br />6 of 6 <br />