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SA Id J O A Q U IN Environmental Health Department <br /> — COUNTY— <br /> RECEiV if <br /> AUTHORIZATION TO RELEASE <br /> " 3 2018 <br /> * ANALYTICAL RESULTS <br /> ENVIRONMENTAL HEALTH <br /> * GEOTECHNICAL DATA <br /> DEPARTMENT <br /> * <br /> ENVIRONMENTAL / SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT <br /> (StreetAddress) (City) <br /> HEREBY AUTHORIZE <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR <br /> MY REPRESENTATIVE. <br /> BUSINESS NAME: <br /> (If Applicable) <br /> OWNER: <br /> (Please Print) (Title) <br /> (Owner Signature) (Date) <br /> ADDRESS: <br /> (Mailing Address) <br /> (City) (State) (Zip Code) <br /> PHONE: <br /> 6of6 <br />