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Jan 08 09 12:42p Reliable Petroleum 209-845-8953 p.7 <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 /> *GEOTECI-INICAL DATA <br /> * ENVIRONMENTAUSITE ASSESSMENT INFORMATION <br /> 1,THE UNDERSIGNED OWNER ANDiOR OPERATOR OF THE PROPERTY ANDJOR FACILITY <br /> LOCATED AT <br /> (Streel 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 <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: ( ) <br /> EH 23 046 (Revised 8/3/07) <br /> 4 <br />