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i <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 <br /> AUTHORIZATION TO RELEASE <br /> - *_ANALYTICAL RESULTS <br /> *GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> 1,THE UNDERSIGNED OWNER AND/OR OPERA OR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT <br /> (Street Add ss) I V, (City) <br /> HEREBY AUTHORIZE <br /> (Labora ory) <br /> TO RELEASE ANY AND ALL ANALYTICAL IN ORMATION TO SAN JOAQUI OUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE ND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESE TATIVE. <br /> BUSINESS NAME: <br /> (If Applicable) <br /> OWNER: <br /> (Please Prin (Title <br /> (Owner Sign ure) (Da ) <br /> ADDRESS: <br /> (Mailt g Address) <br /> (City) (State) (Zip Code) <br /> PHONE:( ) <br /> EH 23 046 (Revised 02/20/09) <br /> 5 <br />