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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209)468-3420 Fax: (209)468-3433 E�� <br /> E Vt:LJ <br /> AUTHORIZATION TO RELEASE NOV 21 2017 <br /> *ANALYTICAL RESULTS <br /> ENVIRONMENTAL HEALTH <br /> *GEOTECHNICAL DATA DEPARTMENT <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFO ION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPER AND/OR FACILITY LOCATED AT <br /> (Street Address) I(City) <br /> HEREBY AUTHORIZE <br /> (LaXENTA <br /> TO RELEASE ANY AND ALL ANALYTICAL IN OTO SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT AS SOON AS IT IS AVAILT THE SAME TIME IT IS PROVIDED TO ME OR MY <br /> REP IVE. <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 /> EH 23 046 (Revised 07/21/1 <br /> 6 <br />