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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <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 J <br /> (Street Address) ( iry) <br /> HEREBYAUTHORIZE �Ac Ftc r�� RoofM— !_ tipea)P TIJL <br /> (Laboratory or Consultant) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> ` <br /> BUSINESS NAME: V N O C Pt t-- <br /> (If <br /> (If Applicable) <br /> OWNER/OPERATOR: ��W 2� 1`A t 5Tt1 N S2 . E wty Ca EOI <br /> -��(Please Print)(( (Title) <br /> (Owner/Operator Signature) <br /> ADDRESS: ZOOO Sv i"rE y00 <br /> (Mailing Address) <br /> S P,r—. w,o N C A . q�lS 83 <br /> (City) (State) (Zip Code) <br /> PHONE: (SI C3 <br /> DATE: 'A I 1 ` 19 �- <br /> EH <br /> 23 041 (Revised 7-10-92) Page 9 <br />