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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY RECEIVED <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 NOV 0 9 20135 <br />AUTHORIZATION TO RELEASE ENVIRONMENTAL <br />L4FAITN nr:DARTAAFKIT <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY.Z6CATED AT <br />(Street Address) (City) <br />HEREBY <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMA ON SA JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SOON AS IT IS AVAILABLE A AT SAME TIME IT IS PROVIDED TO ME OR MY <br />REPRE NT IVE. <br />BUSINESS NAME: <br />(I plicable <br />OWNER: <br />(Please Print) (Title) <br />(Owner Signature) (Date) <br />ADDRESS: <br />PHONE: <br />EH 23 046 (Revised07/17/14) <br />(Mailing Address) <br />(City) (State) (Zip Code) <br />11 <br />