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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />(209) 468-3420 <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INFORMA <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY <br />LOCATED AT <br />(Street Address) <br />HEREBY AUTHORIZE <br />(Labo/E. <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMSAN <br />DEPARTMENT AS SOON AS IT IS AVAILABLE AND ATME <br />TIME IT IS PROVIDED TOME OR MY REPRESENTAT <br />BUSINESS NAME: <br />(If Applicable) <br />OWNER/OPERATOR: <br />(Please Pri ) (Title) <br />(Own /Operator Signature) (Date) <br />ADDRESS: 4�1' <br />(Mailing Address) <br />(City) <br />PHONE: <br />EH 23 046 (Revised 1/24/02) <br />FACILITY <br />COUNTY ENVIRONMENTAL HEALTH <br />(State) (Zip Code) <br />n- <br />