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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> { (209)468-3420 !'i <br /> AUTHORIZATION TO RELEASE <br /> , <br /> " ANALYTICAL RESULTS <br /> * GEOTECHNICAL DATA <br /> i <br /> j * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/DR FACILITY <br /> ij <br /> LOCATED AT 3-S-s© Oc>. ��Tnr k ',A <br /> (Street Address) i (City) <br /> HEREBY AUTHORIZE a~ L <br /> (Laboratory) it <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> ,,. <br /> HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> :I <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> 1 <br /> t <br /> BUSINESS NAME: LA E 44 l <br /> (If Applicable) <br /> OWNER! ERATOR: Y Yt �- � U o <br /> (Please Print) i; {Title) <br />` rsrL4nr(c 1'n L�1lb <br />` (Owner/Operator Signature) (Date) <br /> ADDRESS: 3r`✓' �C' l�L . � �-`Y i � � ?d� <br /> (Mailing Address) p <br /> (Cit},) (State) (Zip Code) <br /> PHONE: <br /> , <br /> EH 23 046 (Revised 10119198) Page 9 11 <br /> f <br />