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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 />I, THE UNDERSIGNED OWNS ND/OR OPERATOR OF THE PROPERTY AND/OR F <br />LOCATED AT <br />(Street Address) (Cita) <br />HEREBY AUTHORIZE <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMAT N TO N JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT T ME <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIV . <br />BUSINESS NAME: _ <br />(If Applicable) <br />OWNER: <br />(Pie e Print) (Title) <br />(Owner Signature) (Date) <br />ADDRESS: <br />(Mailing Address) <br />(City) (State) (Zip Code) <br />PONE: <br />17 <br />EH 23 046 (Revised 02120/09) <br />9 <br />