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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> (209)468-3420 <br /> AUTHORIZATION TO RELEASE <br /> *ANALYTICAL RESULTS <br /> *GEOTECHNICAL DATA <br /> * ENVIRONMENTAUSITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT <br /> f S5 3 Lo l otld IRC:( V) , 19orli Ct0 <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: Loves S sr-OAC <br /> (If Applicable) <br /> OWNER/OPERATOR: <br /> L.0vEs -FA 1�svF L- �!)7-o C o LLNrf�.� <br /> (Please Print) (Title) <br /> (Owner/Operator Signature) (Date) <br /> ADDRESS: 1 U(D 0 f tJ b k t <br /> (Mailing Address) ` j� <br /> © � J\ lilt �"1` � Ji �h7 <br /> (City) (State) (Zip Code)-7 ( �} <br /> PHONE:( q f' S ) 5 ( q d O O F X, -"(405) <br /> ! <br /> EH 23 046 (Revised 1/24/02) <br />