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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> (209)468-3420 r �t <br /> 4 <br /> AUTHORIZATION TO RELEASE <br /> *ANALYTICAL RESULTS <br /> *GEOTECHNICAL DATA <br /> * ENVIRONMENTA ISITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT <br /> 1 � GOU / C <br /> (Street AddreS) cC Y/trot ' CL l 3 v <br /> (City) <br /> HEREBY AUTHORIZE <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: L/ <br /> (If Applicable) <br /> OWNER/OPERATOR: <br /> (Please Prmt) (Title) <br /> (Owner/Operator Signature) (Date) <br /> ADDRESS: f.s-6 o o S , /f :..r-levy `�� t' . <br /> / � (Mailing Address) <br /> '� ky-oz C74- f s > > O <br /> (City) (State) (Zip Code) <br /> PHONE:( <br /> EH 23 046 (Revised 1/24/02) <br /> 6 <br /> 2 'd 2469-194 (602) umojg 81jje0 eLi :80 20 S2 meow <br />