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NOT'APPLICABLE - NO SOIL TE-STING 3cZ*101» <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> AUTHORIZATION TO RELEASE <br /> * ANALYTICAL RESULTS <br /> "GEOTECHNICAL DATA <br /> • FNVIRONMF,NTALiSITF.ASSESSMENT INFORMATION <br /> 1,THE UNDERSIGNED 0%VNFR AND%OR OPERATOR OF THE PROPERTY AND;CIR FACILITY LOCATED AT <br /> (Shut Address) (0n) <br /> HEREBY AUTHORIZE <br /> I' aba <br /> slap) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR MY <br /> REPRESENTATIVE. <br /> BUSINESS NAME: <br /> (If Applicable) <br /> OWNER: <br /> (Please Print) (Till¢) <br /> (Owner Signature) (L)cae) <br /> ADDRESS. <br /> (AfaiGng Address) <br /> (Cih) (State) (Zip Code) <br /> EH21046 (Revised 07t21110) <br /> 6 <br />