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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY ' I <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 A 1 <br /> AUTHORIZATION TO RELEASE <br /> *ANALYTICAL RESULTS <br /> *GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATIO <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTYAN R FACILITY <br /> LOCATED AT <br /> (Street Address) ity) <br /> HEREBY AUTHORIZE <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION T SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT T AME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIV <br /> BUSINESS NAME: <br /> (If Applicable) <br /> OWNER: <br /> (Please Print) (Title) <br /> (Owner i' ature) (Date) <br /> ADDRESS: <br /> -7 (Mailing Address) <br /> (City) (State) (Zip Code) <br /> PHONE: <br /> EH 23 046 (Revised 02/20/09) <br /> 5 <br />