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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOA UIN COUNTY <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 77 <br /> AUTHORIZATION TO RELEASE <br /> * ANALYTICAL RESULTS <br /> *GEOTECHNICAL DATA <br /> * .NVIRONMENTAL/SITE ASSESSMENT INFORM <br /> I,THE UNDERSIGNED OWNER AND R OPERATOR OF THE PROPERTY ND/OR FACILITY <br /> LOCATED AT <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> ( borator <br /> TO RELEASE ANY AND ALL ANALYTICAL INFOR ON TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESEN ATIVE. <br /> BUSINESS NAME: <br /> -- -- - —(lf Applicable) <br /> OWNER/OPERATOR: <br /> (Pleas Print) --- (Title) <br /> caner/Operator Signature) (Date) <br /> ADDRESS: <br /> -- <br /> ("wailing,I ddress) <br /> (City) (State) (Zip Code) <br /> PHO/'46 (Revised <br /> EH 23 8/3/07) <br /> 4 <br />