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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />(2091468-3420 <br />N A- AUTHORIZATION TO RELEASE <br />" ANALYTICAL RESULTS <br />`(iFOTF.('HNIC'AL. DATA <br />` ENVIRONMENTAUSITI•: ASSESSMENT INFORMATION <br />1• THE UNDFRSI(iNF.D OWNER AND/OR OPERATOR OF THF. PROPERTY AND/OR FACILITY <br />LOCATED AT <br />(Street Addreca) (Cin') <br />HEREBY AUTHORIZE <br />(Loiurmog) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION To SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THI' SAME <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: <br />(l/ Applirahl, ) <br />OWNER/OPERATOR: <br />(Plea", Pnm/ <br />/Title/ <br />/Owner/Operator Siy,.naturel (Date) <br />ADDRESS: <br />PHONE: ( <br />FH 23 046 (Revised 1/24/02) <br />(Mailigq Add,e ,) <br />(Cin.) (Slate/ (7.ip Code) <br />6 <br />