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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3470 <br /> AUTHORIZATION TO RELEASE <br /> • ANALYTICAL RESULTS <br /> • OEOTECHNICAL DATA <br /> • ENVIRONMENTALJSITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> fIY <br /> LOCATED AT �n'7 ��' r'C;tJt'�l'�(? : C.4 : <br /> (Street Address ,qq (City) <br /> HEREBY AUTHORIZE <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 /> BUSINESS NAME: JP>e/NT <br /> (If Applicable) <br /> OWNER/OPERATOR: 1Y612 [7Fl2F T- P/ 5 <br /> (Please Print) (IMle) <br /> - <br /> (O ner Perator Signature) <br /> ADDRESS: _ql-)/ 6437— /05/ �' S <br /> ;(M�ailg Address) <br /> .(n/SA.S �7,'Ti/ /1,(a <br /> (City) (State) (Zip Code): <br /> PHONE: ( <br /> DATE: /�y3 <br /> EH 23 041 (Revised 7-10-92) Page 9 <br />