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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 /> • ENVIRONMENTAUSITE ASSESSMENT INFORMATION <br /> 1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY �l <br /> LOCATED AT / 1jVQr 0/1 to or / // If ,00, 1 OT lr�Gu/7 <br /> (Save(Addresso,. (city) <br /> HEREBY AUTHORIZE �DG1�aP C I2chna �oaT <br /> (Lab&Wory or ConsuUoat) <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. O <br /> BUSINESS NAME: A&k I S n"1 I D,2eI'Rani <br /> (!fApplicable) <br /> OWNER/OPERATOR: <br /> (Please Print) // (Title) <br /> DLA <br /> ( /Operator Signature) . <br /> ADDRESS: ' 0` <br /> Mailing Address) <br /> San �o�na d L o CA 9 ago 6 <br /> (City) (State) (Zip Code) <br /> PHONE: (C C 1 ) 3 17( — SIO Sv7, <br /> DATE: <br /> EH 23 041 (Revised 7-10-92) Page 9 <br />