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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 /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT �I2V W « ve,,V- / <br /> (Street A r s) (City) <br /> HEREBY AUTHORIZE <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: SIA <br /> (If Applicable) <br /> OWNER/OPERATOR: CA9L 0AWAAA ITP- <br /> (/Please Print) (Title) <br /> __4 ( ,f/ 9 /��r kA <br /> (Owner/Operator Siig/n=re_), 1 (Date) <br /> ADDRESS: 47S G✓ STI <br /> (Mailing Address) <br /> n. cA9;3 Iry <br /> (city) V (State) (Zip Code) <br /> PHONE: ( Iy I ) 7_� 6 O C O S <br /> EH 23 046 (Revised 9111/96) Page 9 <br />