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02/20/2008 WED 15: 25 FAX 2094683433 SJC EHD -•-- Stockton Sery Sta Eq Co 11(JU06/0Ub <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 'Teleplione: (209)468-3420 Fax: (209)468-3433 <br /> AUTHORIZATION TO RELEASE <br /> *ANALYTICAI.RESULTS <br /> *GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> 1,THE UNDERSIGNED OWNER AND/OR OPER A"f It OF THE PROPER'T'Y AND/OR FACILITY <br /> 4 <br /> LOCATED AT <br /> -------__—..--(Sh•eet Address) -- .— — (City)`:-=---—� <br /> HEREBY AUTHORIZE <br /> y --•-----------------_..__ (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAI.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 /> (!f Applicable) <br /> OWNERJOPFRATOR: <br /> ____----•-(Please Print) `------- (�tle) —_._... <br /> (Owner/Operator Signature) (Date) <br /> (Mailing Add ess) <br /> - -- - __ - —(City) (State) (Zip Code) <br /> PHONE:(___--�—_ _..___..-----__ ---------- — <br /> EH 23 046 (Revised 8/3/07) <br /> 4 <br />