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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 /> ENVIRONMENTALISITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/0R FACILITY <br /> i <br /> LOCATED AT . 17—P z K. sh�rw R afro S 7-OC,K TOA/ <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <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. i <br /> BUSINESS NAME: S/��• Tyi✓ Tom'!'/�t//¢G Fh►Si�'2�l ��� ��� <br /> (If Applicable) <br /> OWNER/OPERATOR: t <br /> (Ple nt) (Tule) . <br /> (Owner/006mtor Signatu (Date) <br /> ADDRESS: 1336 HO,e7W g��4cw�9Y <br /> (Mailing Address) <br /> SToY -7a.✓ C- 4. 5�-SLo <br /> (City) (State) (Lip Code) <br /> PHONE: (4- <br /> EH <br /> ZEH 23 046 (Revised 9/11/96) ' Page 9 <br /> i <br />