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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 />* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT 8 && o Lo we -R �.g C04 M El,l TV ZD . <br />Stree ddress) S'To(city) <br />HEREBY AUTHORIZE S� (360 &YEWtAt- <br />, <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 />BUSINESS NAME: `VeVXOA� s7iT/aA! -09'.323 z <br />(If Applicable) <br />AL OWNER/OPERATOR: V <br />(PI <br />(Owner/ pest Signature) (Date) <br />ADDRESS: 6OO / OC,Lft ae �':�":�✓ <br />(Mailing Address) <br />�s83 <br />L (City) % Q (S e) (Zip Code) <br />PHONE: ( 7 / �) TT 16'y <br />EH 23 046 (Revised 9/11/96) Page 9 <br />