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%woo 1�wo <br /> SAN IOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DMSION <br /> (209) 468-3420 <br /> AUTHORIZATION TO RELEASE <br /> ' ANALYTICAL RESULTS <br /> • GEOTECHNICAL DATA <br /> " ENVIRONMENTAIJSITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILItTY/ <br /> W � <br /> LOCATED AT gslab � L a IJ�l� 2,d RA `�-iy 9 <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE _ <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN IOAQUIN 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 /> BUSL`IESS NAME: SCA-u75y 1 <br /> (If Applicable) <br /> OWNER/OPERATOR: <br /> (Please Print) (Title) <br /> Z7cl c <br /> Owner/ erator S <br /> e) <br /> ADDRESS: <br /> ADDRESS: �� �t U� � <br /> (Mailing Address) <br /> rg:6T,� 95316 <br /> (City) (State) Zp Code) <br /> PHONE: 83 6- T338R <br /> r <br /> EH 23 046 (Revised 7/10196) Page 9 <br />