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Ski*JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 46&3420 <br /> AUTHORIZATION TO RELEASE <br /> ' ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> E-\tiItONMENTAUSITE ASSESSMENT INFORMATION <br /> L THE UNDERSIGNED OR1-ER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 2'500 ALL-16 V-1 t LE PSP09 <br /> (S_:et Address) (city) <br /> HEREBYAUTHORIZE IN4G <br /> r. (Laboratory or Consultant) <br /> TO RELEASE ANY AND ALL A.�'ALYTICAL 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: p�GI�CL FAL <br /> (If Applicable) <br /> ` OWNEWOPERATOR: WC-4k Ao , LxE5 �s� -�kYss GoUSUi 'r <br /> lease a t) / (Title) <br /> V (Owner/Operator Signature) <br /> ADDRESS: IF3j R 1VIC.I rLJrJ� FAV 17 <br /> (bfailing Address) <br /> f�i�Tp L UIL4 GA d1 Lf-e3-r7& <br /> (Ciry) (State) (Zip Code) <br /> PHONE: 119lf5- kf(0& <br /> DATE: <br /> EH 23 041 (Revised 7-10-92) Page 9 <br />