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Hnr KLHL ,LbIHIL ctrl Ii) : 7U1f'65)ouI hili 11 '16 16 : L1 NO .OUL P .02 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3420 <br /> AUTHORIZATION TO RELEASE <br /> • ANALYTICAL RESULTS <br /> • OL•OTECIINICAL DATA <br /> • <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> 1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT �'L W Q&4 joc-q, Kk4 NY& MPS c5, <br /> Streit Addreul JC++Y) <br /> HEREBY AUTHORIZE ory <br /> ((Aborabom lery) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT 15 AVAILABLE AND AT THF SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: A)3F F► rs.t� � _ -- <br /> /` (Udpplicabie) <br /> OWNF-RIOPERATOR: C4i-;4 <br /> (Please Print) (1'ltle) <br /> (Owner/operator 318"alure) (Date) <br /> ADDRESS- _ P. P. UQ X _�00 YL <br /> (Moillq Addrerr) <br /> F(/l- t S J•. ; ti 1/2 72 91 7 - 00 gt S- _- <br /> /City) (State) (lip Cade) <br /> PHONE: ( SDI ) 7 �S fj�o3 g <br /> EH 23 046 (Rcri5e4 9/11/96) Pajc 9 <br />