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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209),468-3420 Fax: (209) 468-3433 <br /> RECEIVE® <br /> AUTHO ZATION TO RELEASE <br /> JUN 0 6 2017 <br /> *ANALYTICAL RESULTS <br /> ENVIRONMENTAL HEALTH <br /> *GEOTECHNICAL DATA DEPARTMENT <br /> * ENVIRNTAL/SITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED WNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT <br /> (Stre t Address) (City) <br /> HEREBY AUTHORIZE <br /> (Labo <br /> ratory) <br /> TO RELEASE A AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEP NT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR MY <br /> REPRESENTATIVE. <br /> BUSINES NAME. <br /> (yApplicable) <br /> O R: <br /> (Please Print) (Title) <br /> (Owner Signature) (Date) <br /> ADDRESS: <br /> (Mailing Address) <br /> (City) (State) (Zip Code) <br /> PHONE:( ) <br /> EH 23 046 (Revised 07/21/10) <br /> 6 <br />