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ME <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DMSION <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 <br />(Street Address) (un) <br />HEREBY AUTHORIZE /✓o(LTu STAT 7�4L— SBS <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br />HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESSNAME: D/.5-7�-/6c,//on D!Vof 5a�A jo_!T: r///1 <br />(If Applicable) / <br />OWNEWOPERATOR: La-a�/ ence R. /wfi��n dlef Zs��toi1 SPIr�/c/es <br />(Please Print) (rule) <br />� <br />; /v /OlZO0,P <br />Signature) <br />ADDRESS: A O. B0X 9E oo.0I <br />(Mailing Address) <br />SfoaA£ f �I G,4% 9SZ 96 <br />(City) (State) (lip Code) <br />PHONE:( 205? ) 092 — 3 <br />EH 23 046 (Revised 9/11/96) Ps_e 9 <br />