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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 />* ENV NMENTAL/SITE ASSESSMENT INFO TION <br />I, THE UNDERSIGNED OWNER AND/OR OP TOR OF THE PROPER AND/O ACILITY <br />LOCATED AT <br />(Street Address) <br />HEREBY AUTHORIZE <br />TO RELEASE ANY AND ALL ANALYTICAL IN ORI✓ <br />DEPARTMENT AS SOON AS IT IS AVAILABL AND <br />TIME IT IS PROVIDED TO ME OR MY REPRES ) Tj <br />BUSINESS NAME: <br />OWNER: <br />(Please <br />ADDRESS: <br />PHONE: <br />EH 23 046V(Revd 02/20/09) <br />JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />(Title) <br />Signature) (Date) <br />(Mailing Address) <br />(City) (State) (Zip Code) <br />5 <br />