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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY RECEIVED <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />JAiu 0 5 2018 <br />AUTHORIZATION TO RELEASE <br />ENVIRONMENTAL HEALTH <br />* ANALYTICAL RESULTS DEPARTMENT <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE <br />TO RELEASE ANYKND ALL ANALY AL <br />DEPARTMENT AS SOON AS IT ISXV <br />BUSINESS NAME: <br />ADDRESS: <br />PHONE: ( ) <br />THE PROPERTY AND/OR FAVILITY LOCATED AT <br />(City) <br />M BY AUTHORIZE <br />(Laboratory) <br />RMATION TO AN AQUIN COUNTY ENVIRONMENTAL HEALTH <br />BLE AND AT AME TIME IT IS PROVIDED TO ME OR MY <br />REPRESENTATI <br />(IjA 'cable) <br />(Pleas Print) <br />(Own r Signature) <br />(Mailing Address) <br />(City) <br />EH230038 (revised 12-11-15) 6 <br />(Title) <br />(Date) <br />(State) (Zip Code) <br />