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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 ASSESSME N-T INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT Z—7j / 5"2-[1 <br /> (Street Address) ,,/ �y� (city) <br /> HF-RE13Y AUTHORIZE (� -/7—/ a <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 15 AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. t <br /> r <br /> s <br /> BUSINESS NAME: //_� C/ f p <br /> l�G C7ps,f <br /> {If Applicablea <br /> OWNERIOPERATOR: � / <br /> (Please Print) (Title) <br /> (Owner/Operator Sign r (Date) <br /> ADDRESS: ,s' y <br /> (Mailing Address) <br /> (Guy) (State) (Zip Cade) <br /> PHONE: ( 2,0 RC1 $5 <br /> EH 23 046 (Revised 0$/13/99) Page 9 <br /> dd Wd90:80 b002 TO 'ada LS8T-892 602 : 'ON XUJ ONI `SIO adNORL WIr WOdA <br />