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SAN JOAQuIN COUNTY <br /> ENVIRONMENTAL HLALTH DEPARTMENT <br /> (201))416X-W20 <br /> AUTHORIZATION TO RELEASE <br /> -1NAl.l'1'f('AI. RESULTS <br /> At. DATA <br /> ` FNVIRONMI:NTALIS ITF ASSFSSMENT INFORMATION <br /> 1, THE UNDF.RSI(;NFD OWNER AND/OR OPERATOR OF THI- PROPF•RTY AND/OR FACILITY <br /> LOCATED Al <br /> (Street 4ddress) <br /> (Citt•) <br /> HEREBY AUTHORIZL <br /> (Laborator)y <br /> TO RELEASE ANY AND ALL ANALYTIC'AL INFORMATION 1'O SAN JO AQUIN COUNTY FNVIRONMF.NTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THI• SAMI <br /> TIME IT IS PROVIDED TU MF OR MY REPRFSFNTA"f IVI-. <br /> BUSINESS NAMF <br /> Il/.I jq�liez�hle•I <br /> OWNFR/OPFRATUR: <br /> (Pleas"Print) <br /> (Ti Ne) <br /> ADDRESS: (Un'ner/(Perator Stl?nufure) <br /> IDutc•I <br /> 0Vfuiba l addres•.sl <br /> (C'ihv <br /> PH()NF: <br /> (.State) (7.ip Code) <br /> ( 1 <br /> EH 23 046 (Revised 1,124102) <br /> 6 <br />