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hKum P 12 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DMSION <br /> (209)468-3420 <br /> AUTHORIZATION TO RELEASE <br /> • ANALYTICAL RESULTS <br /> • GEOTECHNICAL DATA <br /> ENVIRONMENTAIJSITB ASSESSMENT L`IFORMATION <br /> 1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY ANDlOR FACILITY <br /> LOCATED AT _75pty W, (-INNF- KrPrP <br /> (Srreer Address) (Cry) <br /> HEREBY AUTHORIZE <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES-FNVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT 1S PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: c -C7�scuJ Sc�1oa �rCl c� <br /> (If Applicable) <br /> OWNER/OPERATOR: (LArn)c <br /> (Please Print) <br /> (Owner/Operator Signature) (Date) <br /> ADDRESS: `767Jd G� /N/J� (ROP) <br /> (Marling Address) <br /> C69 9�637G <br /> Klly) (Stare) alp Cade) <br /> PHONE: ( "zO 9) 4126 --?ZLL - <br /> EH 23 046 (Revised 10/19/98) Page 9 <br />