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To: Page 8 of 10 2015-12-01 00:49:17(GMT) 14153999602 From: t•likola ZAGOROV <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Y <br /> Telephone:..(209)468-3420 Fax: (209)468-3433 <br /> AUTHORIZATION TO RELEASE mEGEIVED <br /> -----.................--- -- NOV 3 0 2015 <br /> ANALYTICAL RESULTS <br /> *c� OTscx>�'IcaLDArA ENVIRONMENTAL <br /> HFAI Ti4 n;=PARTIU i:NIT <br /> * ENVIROMNENTALISI`i'E:AS$ESSMENT1.NFOR,\4ATiON <br /> L THE UNDERSIGNED OWNER AND/OR OFERATOIR.OF THE PROPERTY AND/OR FA.Ci UT'Y LOCATED AT <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> (Laboratory) <br /> TO RELEASE&NY AND ALL ANA'LYT[CAL.tNFOMIATION TO SAN OAQU,24 COUNTY EN-.vq tONMENTAL HEALTH <br /> DEI'AR7 WENT AS SOON AS IT IS AVAILABLE AND AT TkM SAME T7.ivfE IT IS MOVIDED TO ME OR MY <br /> REPRESENTATIVE. <br /> BUST M NAME: <br /> (Ppplkahle) <br /> OWNER- <br /> mewe Printf <br /> (Owner Signature) <br /> ADDRESS: <br /> (Nldilr'ng.A.ddress) <br /> (City) (State) (Zip Coale) <br /> PHONE:( ) <br /> EH 23 046 (Revised 07/17114) <br /> 6 <br />