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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> (209)468-3420 <br /> 0- AUTHORIZATION TO RELEASE <br /> * ANALYTICAL RESULTS <br /> *GEOTF('HNICAL. DATA <br /> ENVIRONMENTAUSITL:ASSESSMENT INFORMATION <br /> 1,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THF. PROPERTY AND/OR FACILITY <br /> L(X'ATED AT <br /> (Street Address) (Citty <br /> HEREBY AUTHORIZE <br /> (Laboratory,) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THF SAMF. <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME <br /> (l%Applicahlcl <br /> OWNER/OPERATOR: <br /> (Please Prim) (Title) <br /> (Owner! for Signature) (Date) <br /> ADDRESS: <br /> (Mailing Address) <br /> (City (State) (74;Code) <br /> PHONE:( ) <br /> EH 23 046 (Revised 1/24/02) <br /> 6 <br />