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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 <br /> AUTHORIZATION TO RELEASE <br /> *ANALYTICAL RESULTS <br /> z GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> L THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT <br /> (StreetAddress) (City) <br /> HEREBY AUTHORIZE <br /> (LaboratorJ) <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 SAYM <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: <br /> (If Applicable) <br /> OWNER/OPERATOR <br /> (Please Print) (Title) <br /> (Owner/Operator Signature) (Date) <br /> ADDRESS: <br /> . . (Mailing Address) - <br /> (city) (State) (Zip Code) <br /> PHONE:( I <br /> z wEnz <br /> EH 23 046 `(Revised 8/3/07) <br /> .,r <br /> P- <br /> �. : <br /> ;� '�;�• x r �� <br />