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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209)466-3420 <br /> AUTHORIZATION TO RELEASE <br /> ' ANALYTICAL RESULTS <br /> ' GEOTECHNICAL DATA <br /> ` ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> 1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT )"i 3 I L.V-:� r Ma V, pct 3a ZC1t S 106 CA� toL, <br /> (Street Addre ) (City) <br /> HEREBY AUTHORIZE A4- IB_�l nr ov'rin 1C� <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: __ ZA� Yt 11 a\n..vn "6 <br /> (If Applicable) <br /> OWNER/OPERATOR: " f. I, IL6 STk ma P <br /> (Please Print) (Tit <br /> (Owner/Operator Signature) (Date) <br /> ADDRESS: Po-_ �Z o X 0r) t o <br /> (Mailing Address) <br /> (City) ,J (State) (Zip Code) <br /> PHONE: (�0 GI <br /> EH 23 046 (Revised 08/13/99) Page 9 <br />