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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />. [OWN ON IN <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT <br />(Street <br />(City) <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICALO TION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS N AS IT IS AVAILABLE ND AT THE SAME <br />TIME IT IS PROVIDED TO ME OR MY REPRESEN TIVE. <br />(If Applicable) <br />(Please Print) <br />(Owner Signature) (Date) <br />(Mailing Address) <br />(City) <br />EH 23 046 (Revised 02/20/09) <br />61 <br />(State) (Zip Code) <br />