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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fag: (209) 468-3433 <br />.i�FOFIVED <br />AUTHORIZATION TO RELEASE <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />_mL16 2018 <br />ENVIRONMENTAL <br />HEAI.TH F1FPAPTNAENT <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT <br />(Street Address) (City) <br />HEREBY AUTHORIZE <br />(Laboratory) <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 />e %NT -1 U <br />(Please Print) (Title) <br />(Owner Signature) <br />ADDRESS: <br />(Mailing Address) <br />(City) <br />PHONE: <br />EH230038 (revised 12-11-15) 6 <br />(Date) <br />(State) (Zip Code) <br />