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<br /> <br />1868 E. Hazelton Avenue | Stockton, California 95205 | T 209 468-3420 | F 209 464-0138 | www.sjcehd.com <br />Environmental Health Department <br />AUTHORIZATION TO RELEASE ANALYTICAL INFORMATION <br />TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> <br /> <br />All analytical results for tank, piping, dispenser, and stockpile sampling shall be sent directly to the San <br />Joaquin County Environmental Health Department (EHD) underground storage tank program email <br />address (ust@sjgov.org). Only results that are sent directly to EHD from a third-party California <br />accredited environmental laboratory, with an affixed chain of custody, will be accepted. Analytical <br />results must be submitted within 30 days after the tank closure date. <br /> <br /> <br />OWNER/OPERATOR INFORMATION <br /> <br />OWNER/OPERATOR NAME: ________________________________________________________ TITLE: ______________________ <br /> First Last <br /> <br />BUSINESS NAME: _____________________________________________________________________________________________ <br /> <br /> <br />EMAIL ADDRESS: ______________________________________________________________ PHONE: _______________________ <br /> <br /> <br /> <br /> <br /> <br />I, the undersigned owner and/or operator of the property and/or facility located at <br /> <br />_______________________________________________________________________ <br />Facility Street Address & City <br /> <br />hereby authorize the following laboratory <br /> <br />________________________________________________________________________ <br />ELAP Certified Laboratory Name <br /> <br />________________________________________________________________________ <br />ELAP Certified Laboratory Address <br /> <br />to release any and all analytical information directly to the San Joaquin County Environmental Health <br />Department as soon as it is available and at the same time it is provided to me or my representative. <br />This authorization includes analytical results and information, geotechnical data, and <br />environmental/site assessment information. <br /> <br /> <br /> <br />OWNER/OPERATOR SIGNATURE: _________________________________________________ DATE: ______________ <br /> <br /> <br /> <br /> <br /> <br />