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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209)468-3420 Fax: (209)468-3433 <br /> AUTHORIZATION TO RELEASE <br /> *ANALYTICAL RESULTS <br /> *GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT <br /> fit-5— 'dFw074 40" s t e <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL <br /> HEALTH DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR MY <br /> REPRESENTATIVE. <br /> BUSINESS NAME: AiPL�D >� DLO 910 <br /> rt v t I/ (lfrAApplicable) , <br /> OWNER: j T Ca.e�>r T r o.�. /s LG G ,L avti r-_ �,.►._ J', <br /> (Please Print) Mile)�T <br /> /D/ <br /> (Owner Signature) (Date) <br /> ADDRESS: <br /> (Mailing Address) <br /> (City) (State) (Zip Code) <br /> PHONE:( <br /> EH 23 046 (Revised 07/21/10) <br /> 6 <br />