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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 /> • ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT S5� W (W e 2A c 1-O>~- <br /> (Street ddress) - (City) <br /> HEREBY AUTHORIZE <br /> (LaborgWy or Co sultant) <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 TO <br /> ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME : <br /> (If Applicable) <br /> OWNER/OPERATOR : cQ <br /> (Please Prim (Title) <br /> (Ownedope or ignature) <br /> ADDRESS: 119x00 S. /Ln iuty S�, <br /> (Mailing Address) <br /> -hgTA f CA- CAF a'S3 3 ('0 <br /> (city) (State) (Lip) <br /> PHONE: ) <br /> DATE: <br /> Page 8 <br /> EH 23 041 (RoAa d 7-10-02) <br />