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.ui.1sC U1• tlu:Sl It I , ,1oii 0 Ljj t� I tll;:il. 1 != i,; �_.€ )+ _ :€�;! •.I:.:+u,l <br /> C4 0I,I,', )un, f` na fair .+f l u:11 <br />_ 1f,Ji L:a::! 1i:.:f::l tyiy i,ti•f:nrlu, I'. O. €1:,, :iy.�+', ' qq <br /> .+Ilsunatic Van Sp+Unaan <br /> S lw: lon,kCaMornia U:,'.'O1 <br /> - n f s.nantnl �� Cay of 1..prrfoco <br /> - _ (:fly cf fllpOn <br /> j Gpueu 2(7r1/aG(i-6781 MI).:.nlal L. � ,„tiJ rl r_�' fMI).p1 Ston <br /> ckln <br /> Flprr.l <br /> ] ci:y Ulf I+ncy <br /> nlrn A. Float. M.D. <br /> +:fllufn J.4Yaria JopE><Gan.1a,him'. l.t.E',lf,• UlalrlCl Flr,nllh Ut[Itrur I,,' _(•_r:L�rZtJu�qulnC<)unty <br /> �1r`f!:4`•:•'~..L i�.LS:.a;l Ju.r�Jlt$Ca)nr+t <br /> 5 �'1<ry Annr Lcrra i .I:.Ii.1�.�..,1\'� <br /> AUTHORIZATION TO RELEASE ,"NALYTICAL !2ESULTS, GEOTCniflICAt DATA AND <br /> SITE ASSESSMENT INFORI-MION <br /> I, the undersigned owner and/or operator of the property and/or facility <br /> locaLed at _1`7 3o> x + �a`��-`'-•��mc� -3- - <br /> hereby authorize <br /> to release any and all analytical r•e::ul ts. 900tcchnlCal da" and site <br /> ssessment information to tlIle San Joaquin Local Health District ;:s soon <br /> as it is available and at the same tiFre it is i filled to it Or my <br /> representativL-. <br /> rl <br /> Tie: <br /> _— �� t .G <br /> - lhrne�'/4nerator: _ ��•- �" <br /> Address ItAL Phonc: <br /> gid"�a • �'�� _ <br /> Date: <br /> ENV14u:r,a!,IAL HEALTH <br /> F Gi(6Al l/5EfiViGtS, <br /> i.:H 08 05 UGT 13 <br />