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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY RECEIVED <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 SEP 2 6 2016 <br />AUTHORIZATION TO RELEASE <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />ENVIRONMENTAL HEALTH <br />DEPARTMENT <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT <br />(Street Address) (City) <br />HEREBY AUTHORIZE <br />ratory) <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 />ADDRESS: <br />PHONE: <br />EH 23 046 (Revised 07/21/10) <br />(If Applicable) <br />(Please Print) <br />(Owner Signature) <br />(Mailing Address) <br />(City) <br />0 <br />(Title) <br />(Date) <br />(State) (Zip Code) <br />