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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 RECEIVEL, <br />AUTHORIZATION TO RELEASE SEP 2 8 2015 <br />NMENTA!. <br />* ANALYTICAL RESULTS Ir v -u <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <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 />OWNER: <br />ADDRESS: <br />PHONE: ( ) <br />EH 23 046 (Revised 07/17/14) <br />(If Applicable) <br />(Please Print) (Title) <br />(Owner Signature) (Date) <br />(Mailing Address) <br />(City) (State) (Zip Code) <br />0 <br />