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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 DAT;AZ <br /> T101 <br /> ENVIRONMENTAL/SITE ASSESSMENT TION <br /> 1,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE P 1E.RTY /OR FACILITY <br /> LOCATED AT <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTIC ORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT ISA LE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR REPRESENTATIVE. <br /> BUSINESS NAME: <br /> (If Applicable) <br /> OWNER: <br /> (Please Print) (Title) <br /> (Owner Signature) (Date) <br /> ADDRESS: / <br /> (Mailing Address) <br /> (City) (State) (Zip Code) <br /> PH <br /> EH 23 46 (Revised 02/20/09) <br /> 5 <br />