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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 /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FIACIILLITY <br /> LOCATED AT Z 3 ( MW`I DWI c�flC KS1 an� <br /> C (Street Address (City) <br /> HEREBY AUTHORIZE &Xv�%'A C4 b . <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN 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: Lk SA 1' ey1 LC.t a. , C&T O <br /> (Lfapplicable) <br /> 54,_kA IL <br /> OWNER/OPERATOR: �� 4E7p p(; `'/' Gp <br /> (Please Print) (li <br /> (Owner/Operator Signature) (Dati) <br /> ADDRESS: 2 tO I dd I <br /> (Mailing A rens) <br /> PO&�-n,J A co . g (40 <br /> (City) (State) (Zip Code) <br /> PHONE: ( 7,05 ) <br /> EH 23 046 (Revised 9/11/96) Page 9 <br />