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SAN JOAC V COUNTY PUBLIC HEALTH SERVI V i <br /> EN'*i WNMENTAL HEALTH DIVISION <br /> (209) 468-3420 ! ' <br /> AUTHORIZATION TO RELEASE <br /> • ANALYTICAL RESULTS <br /> • GEOTECHNICAL DATA <br /> ENVIRONMENTALJSITE ASSESSMENT INFORMATION <br /> 1,THE UNDERSIGNED OWNER AND/OR OPERATOR OF'1'HE PROPER"I'Y AND/OR FACILITY <br /> LOCATED AT JdD ✓ fin? !�� <br /> (Street Address) (city) <br /> HEREBY AU'T'HORIZE <br /> (Laboratory or ConruU ) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC L <br /> HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND AT TIME SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: 71II nom_ InC <br /> (If Applicable) <br /> ONER/OPERATOR: U <br /> WNt <br /> lease Erin() (7ule) <br /> weer/Operator Signature) <br /> ADDRESS: <br /> (Mailing Address) <br /> Cil- 9s�zl0 <br /> (City) (State) (Zip Code). <br /> PHONE: tl© ag <br /> DATE: <br /> (i <br /> EH 23 041 (Revised 7-10-92) <br /> Page 9 , <br />