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I <br />,125/2002 17:07 2094663 " FIFTH FLOOR PAGE 06 <br />is 0 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />(209) 468-3420 <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAUSITE 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 <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SOON AS 1T IS AVAILABLE AND AT THE SAME <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: <br />OWNER/OPERATOR: <br />AfApplicable) <br />(Please Print) (Title) <br />(Owner/Operator Signature) (Date) <br />ADDRESS: <br />(Mailing Address) <br />(City) <br />PHONE: ( <br />]123 046 (Revised 1/24/02) <br />Page 6 <br />(Slate) (Zip Code) <br />6 <br />