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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY /OR F <br />LOCATED AT <br />(Street Address) <br />HEREBY AUTHORIZE <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TOAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATI <br />BUSINESS NAME: <br />(If Applicable) <br />OWNER/OPERATOR: A) <br />(Please PPfnt) (Title) <br />EH,4 046 (Revised 8/4/06) <br />Signature) (Date) <br />(Mailing Address) <br />(City) (State) (Zip Code) <br />0 <br />