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0 SAN JOAQUIN COUNTY 9 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />(209) 468-3420 <br />AUTHORIZATION TO RELEASE <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AN <br />LOCATED AT <br />(Street Address) <br />HEREBY AUTHORIZE <br />OPERATOR OF THE PROPERTY AND/OR FACILITY <br />(City) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMA ION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SOON AS IT IS AVAILABLE AND ATHE SAME <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: <br />(If Applicable) <br />OWNER/OPERATOR: <br />(Please Print) <br />(Owner/Operator Signature) <br />ADDRESS: <br />(Mailing Address) <br />(city) <br />PHONE: ( ) <br />EH 23 046 (Revised 1/24/02) <br />(Title) <br />(Date) <br />(State) (Zip Code) <br />0 <br />