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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> AUTHORIZATION TO RELEASE <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 <br /> LOCATED AT <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE A <br /> (La oratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFO ATION 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 /> Appl ale) <br /> OWNER: <br /> (Please Print) (Title) <br /> (Owner Signature) ( ) <br /> ADDRESS: <br /> (Mailing Address) <br /> (Cit}) (State) (Zip Code) <br /> PHONE:( ) <br /> EH 23 046 (Revised 02/20/09) <br /> 5 <br />