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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> (209)468-3420 <br /> AUTHORIZATION TO RELEASE <br /> • ANALYTICAL RESULTS <br /> •GEOTFUHNICAL DATA <br /> ' ENVIRONMENTAUSITF ASSESSMENT INFORMATION <br /> 1.THE UNDERSIGNED OWNER AND/OR OPERATOR OF THF PROPERTY AND/OR FACILITY <br /> LOCATED AT <br /> (Scree/Addre%s) (Cin) <br /> HEREBY AUTHORIZE <br /> (Laboratog) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION To SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THP. SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: <br /> (ll Applicahle) <br /> OWNER/OPERATOR: <br /> (Pleure Print) /Title/ <br /> (Owner/Operator Signature) (Date/ <br /> ADDRESS: <br /> Wailing Addreev) <br /> lC'in') (State) (7ip Code) <br /> PHONE: <br /> EH 23 046 (Revised 1/24/02) <br /> 6 <br />