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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 OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT <br /> (Street Address) (City) <br /> HEREBY <br /> AUTHORIZE <br /> (Labaratary) ---i <br /> TO RELEASE ANY AND ALL, ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: <br /> _--(lfAppltcable) <br /> OWNER/OPERATOR: <br /> (Please Print) <br /> (Owner/Operator Signatnre)� (Dare) <br /> ADDRESS: <br /> (MatlinR Address) --- --- <br /> (City) —_'-(Sial") (Ltp C(Xt(t) <br /> PHONE:( �_._.-- -----'-- <br /> EE123046 (Revised8/1/II) g <br />