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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 /> • ENVIRONMENTALISITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 'I,IN �A r,��� }1�QU StoC�tr <br /> (Street Address) (guy) <br /> HEREBY AUTHORIZE <br /> (laborosory of CoasaUant) <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 REPRESENTrA_TIVE. �I pp ,, "" n <br /> BUSINESS NAME: 71Y1 Y)()OJ1�11 (kL���u�tu�litD (1Vlf� UP�OY I"/MtYD� � ilCt <br /> (IfApplicabl CC v I ' <br /> OWNER/OPERATOR: 16hp J11'�7� 1 Ld, <br /> (Ple Print (Title) <br /> er/Operst(or Signature)/ <br /> ADDRESS: <br /> (Mailing Address) Ill l pOl } way <br /> %(Y-bn aA 45� <br /> r(City) n p (State) (Zip Code) <br /> PHONE: <br /> DATE: <br /> tJ `� <br /> EH 23 041 (Revised 7-10-92) Page 9 <br />