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SAN JOAQUIN COUNTY PUBLIC HEALTH.SERVICES <br /> ENVIRONMENT <br /> AL HEALTH_ DIVISION <br /> I' (209) 488-3420 <br /> AUTHORIZATION <br /> 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 W't A'U_ [ 7j 01 o W . G- '�(,, Iu 4..4 �r�dr. <br /> HEREBY AUTHORIZE (Street driress 4 r'1 (City) <br /> rx. <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL AN; <br /> INFORMATION TO SAN JOAQU€N COUNTY PUBLIC <br /> HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE <br /> SAME <br /> TIME ITIS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME. <br /> (If;,Applicable) <br /> OWNER/OPERATOR; <br /> P, ase P t) Mile) <br /> �r <br /> 1 !b <br /> (Owner/operator Signature) (Date) <br /> ADDRESS: r';J P �J• �,�' �� 1 R <br /> (Mailing Address) <br /> u• <br /> CA .a^1 <br /> (city) (State) (Zlp Cade) <br /> PHONE: <br /> t <br /> H 23 046 {Revised 911€/96) Page 9 <br />