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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 46&3420 <br /> AUTHORIZATION TO RELEASE <br /> ' ANALYTICAL RESULTS <br /> * GEOTECHNICAL DATA <br /> • ENVIRONMENTALJSITE ASSESSMENT INFORMATION <br /> 1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT Yy1Z Gtr' A) <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> Laboratwy or ConsukaW) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> s <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: ✓To Ct U/L4 6uo r LS <br /> (If Applicable) nn <br /> OWNER/OPERATOR: q V\ TOA 9(A � CO <br /> /Please Print) (Tale) A <br /> (Owner/Operator gnature) <br /> `� <br /> ADDRESS: -0, Sox <br /> (Mailing Address) <br /> (City) (State) (Zip Code). <br /> PHONE: 120 1 17'C` ` O`CC <br /> DATE: 40 1?1 %3 <br /> EH 23 041 (Revised 7-10-92) Page 9 <br />