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0 <br /> SAN 30AQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209)468-3420 <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 FACILIT4Y� <br /> LOCATED AT Ac�f�i "z_6� - f @� —�-r� " <br /> (Street Address) (City) <br /> 0 <br /> HEREBY AUTHORIZE : L� <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 /> BUSINESS NAME: � C_ :��11 '�°vl+�•Ji� {`►(�•1i �`= �1t T <br /> (If Applicable) <br /> I OWNERIOPERATOR: /yipaff w <br /> (Please Print) (Title) <br /> II (OwnerlOpe ator Sig Lure) ( ate r <br /> 1 ADDRESS: _ Fe> <br /> (Mailing ddress) <br /> (City) {State} (Zip Code) ' <br /> PHONE: { Qpt.'� } 813 <br /> EH 23 046 (Revised 08/13/99) Page 9 <br /> t <br />