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ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone:I' 468-3420 I''468-3433 <br />F.A ■.1/ \ <br />i <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY R FACILITY <br />LOCATED AT <br />(Street Address) (City) <br />HEREBY AUTHORIZE <br />(Laboratory <br />TO RELEASE ANY AND ALL ANALYTICAL INFO ON TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT AS SOON AS IT IS AVAILABLE AND T THE SAME <br />TIME IT IS PROVIDED TO ME OR MY REPRESE ATIVE. <br />BUSINESS NAME: <br />(If Applicable) <br />OWNER/OPERATOR: <br />(P ase Print) (Title) <br />(Owner/Operator Signature) (Date) <br />ADDRESS: <br />(Mailing Address) <br />(City) (State) (Zip Code) <br />046 (Revised 8/4/06) <br />4 <br />