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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209)468-3420 Fax: (249)468 3433 <br /> AUTHORIZATION TO RELEASE <br /> ANALY/ERTY <br /> *GEOTE <br /> * ENVIRONMENTAL/SITE <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF ILITY <br /> LOCATED AT <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> ( aharutory) <br /> TO RELEASE ANY AND ALL ANALYTIC ORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AV LE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR REPRESENTATIVE. <br /> BUSINESS NAME: <br /> (IfApplicahle) <br /> OWNER: <br /> (please print) (Title) <br /> (Owner Signature) (Date) <br /> ADDRESS- <br /> (Mailing Address) <br /> (City) (State) (Zip Cade) <br /> PHO [ } <br /> EH 23 45 (Revised 42C2O/O9) <br /> 5 <br />