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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 3 1 3 3 N/. , A d - A rl Roo 4 S )o c K 1 0 h <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE AIptia ANd1�C1,tctI !_ gborg1Owi • s <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 /> BUSINESS NAME: Ad - ANT <br /> (If Applicable) <br /> OWNMIOPERATORA' &C4!0— gF� SIIe-E1Y !�ll�Ns6Y�F1rZ <br /> (Pl e Print) (Title) <br /> (Owner/Operator Sknaturor (Dari) <br /> ADDRESS: 10. Box '35' 70 <br /> (Mailing Address) <br /> 57ocKToh CAg5z <br /> (City) (State) (Zip Code) <br /> PHONE: (-LO q > 9 31 - 0 8 6 0 <br /> EH 23 046 (Revised 9/11/96) Page 9 <br />