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ilf JVf LVVe 11•JJ LV J'YV VJ"PJJ 1 11 Ili 1 1_VVI\ f HlaC M3 <br /> SAN Y OAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> (209)468-3420 <br /> AUTHORIZATION TO RELEASE <br /> {ANALYTICAL RESULTS <br /> *GEOITECBMCAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL,HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> a <br /> BUSINESS NAME: <br /> (I, ,4ppdicable) <br /> OWNER/OPTOR: <br /> r <br /> (P ase Print) (2'ttte) <br /> ,, (rDw�aer/ pecator Signature) (Rate) <br /> ADDRESS: <br /> (Ma"ingAddress) <br /> (GFty) (State) (tip Code) <br /> PHONE: _) <br /> r` <br /> EH 23 046 (Revised 1/24/02) <br /> 6 <br />