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SAMOAQUIN COUNTY PUBLIC HEALTH SEWeiCES <br /> ENVIRONMENTAL HEALTH DMSION <br /> (209)468-3420 <br /> AUTHORIZATION TO RELEASE <br /> * ANALYTICAL RESULTS <br /> * GEOTECHNICAL DATA <br /> " ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> 1. THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY :? <br /> LOCATED AT 4i•!T Al O. 16oa y <br /> (Street Address) (city) /� I <br /> HEREBY AUTHORIZE blob {kA•.�� LaborA:6r_t S 1:Ac aK. <br /> & le;rife, ✓,Z/1C <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: t=6wLL-n!%- Boot/ zmtfop <br /> (If Applicable) <br /> OWNER/OPERATOR: epUl /--V-1AjL'L 0WA/;/L_ <br /> (Ple a Print) ' Ti !e) <br /> 3 6 � <br /> (Ow er/ perator Signatur ) Da ) <br /> ADDRESS: -4as /VO. jG015rAl S7. <br /> (Mailing Address) <br /> STJe/U&/ <br /> ' <br /> l' (City) (State) (Lip Code) <br /> PHONE: ('40 ) 14 g u:& (o <br /> EH 23 046 (Revised 10/19/98) Page 9 <br />