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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DMSION <br /> (209) 46&3420 <br /> AUTHORIZATION TO RELEASE <br /> • ANALYTICAL RESULTS <br /> • GEOTECHNICAL DATA <br /> ' ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> 114114 x 441 Z-671't <br /> I, THE UNDERSIGNED ppO'�WNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY / <br /> LOCATED AT l- /// 1,4� J/ 57 <br /> (Street Address) /�/ / (City) <br /> HEREBY AUTHORIZE 'd��'' !✓�Up/ ( � <br /> (Laboratory or Consultant) <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 REPRESENTATIVE <br /> n <br /> BUSINESS NAME: 'v \ <br /> (If Applicable) <br /> OWNEWOPERATOR: 'SCTF�W� <br /> (Please Print) (Title) <br /> c_J( <br /> (Owner/Operator ignature) <br /> ADDRESS: r--`0 77e07- <br /> (Mailing Address) <br /> i R.='"1 <br /> (City) /�' (State) (Zip Code) <br /> PHONE: ( � ) f�� `� 7Z <br /> DATE: <br /> EH 23 041 (Revised 7-10-92) Page 9 <br />