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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3420 <br /> AUTHORIZATION TO RELEASE <br /> • ANALYTICAL RESULTS <br /> • GEOTECHNICAL DATA <br /> ' ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> 1, THE UNDERSIGNED OWNER AND/O�/R OPERATOR OF THE PROPFtRTY AND/OR FACILITY <br /> LOCATED AT �� /C. L� IrrrfiaL �C'�U I CO I�1 ra ll 4(-C(LL <br /> (Street Addreso,. _-r_ (City) <br /> HEREBY AUTHORIZE �J[JCR(c,[--? il/10ioc,N/ <br /> (Laborittory or Consultant) <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. I' Q /� <br /> BUSINESS NAME: A l k 1 S oft 1 oge K.o' ctn C) �a,l L 11 60 �e. J�Gl i/Wnt/ CXR . <br /> (If Applicable) }} J <br /> OWNER/OPERATOR: JL1l. L YrIL>/iClrl CL 4CCJy <br /> (Please Print) (Title) <br /> (0"er/Operator ignatute) <br /> ADDRESS: U� `____ _ i Of 1 U Pte' <br /> ( ilinllda gAddress) J <br /> 101n CA 9agrjs <br /> (City) (State) (Zip Code) <br /> PHONE: Ot^ 39(c yO&A <br /> DATE: 7 <br /> EH 23 041 (Revised 7-10-92) Page 9 <br />