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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 4683420 <br /> AUTHORIZATION TO RELEASE <br /> ' ANALYTICAL RESULTS <br /> • GEOTECHNICAL DATA <br /> ENVIRONMENTALiSITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 11`151 IF A9, MQrok GP- gh'�j�Co <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE she-mood Ln <br /> (Laboratory or Consuftant) <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 /> BUSINESS NAME: 0- <br /> (If Applicable) <br /> OWNER/OPERATOR: Annle �jh Uwner <br /> (Please Print) (Tide) <br /> ��2Z�`z 2vv�� <br /> (Owner/Operator Signature) <br /> ADDRESS: )90 601 /b�5 1 . <br /> (Matting Address) <br /> Manubt 1,9- �3�A* <br /> /(City) y ` (State) (Zip Code) <br /> PHONE: ( �/ 1 Oo2�j-�03✓� <br /> DATE: <br /> EH 23 041 (Revised 7.10-92) Page 9 <br />