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i <br /> 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 /> i .. <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> r <br /> LOCATED AT Jas (3 rc&c I14 0 =r—o-,.Lu <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE GeoAnal tical Labor tor' <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 IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> r BUSINESS NAME: IA Z <br /> 1 (If Applicable) <br /> OWNER/OPERATOR: <br /> (Ple Pritle) <br /> r "(Owner/Operator Signature) (Dale) <br /> C <br /> A �rrE <br /> ADDRE5 l��`I� 0o7 ' ,� GI <br /> F <br /> (Mailing Address) <br /> P7 (city) (State) (bp Code) <br /> PHONE: <br /> t• . <br /> i . <br /> rH 23 046 (Revised 9/11/96) Page 9 <br /> I <br /> F <br /> i <br /> i <br />