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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (7.09) 468-3420 <br /> AUTHORIZATION TO RELEASE <br /> ANALYTICAL RESULTS <br /> ' GEOTECHNICAL DATA <br /> • ENVIRONMENTAUSITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATEDAT 2.3 F . m V g,n_Ir <br /> ( eet Address) (C4) <br /> HEREBY AUTHORIZE V V1 Er- 'P- N <br /> (L.aboratay or a ssultant) <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: �t�r�"L I �c / A C:/"-J�, T-, <br /> (If Applicable) -- - ---- -- _- <br /> O WNER/OPERATOR: 6FL%e,G Win•__ ,�'�t= { Tc�l�i _ � -._. <br /> (Please Print) (Title) <br /> (a,,-Z4 <br /> tl, �K= <br /> ( /Ope for Signature) <br /> ADDRESS: rZ ' e'f <br /> (Mailing Address <br /> (City) (State) (Zip Code) <br /> PHONE: Z <br /> DATE: C�Z- <br /> EH 23 041 (Revised 7-10-92) Page 9 <br />