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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 4511- GIr1'1 C. Ave'. <br /> (Street Adi rTe ��v, 1� ( tY) <br /> HEREBY AUTHORIZE (;,Q, i r a �P�I <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: �q G 1 L I ► 1 7 �S <br /> (If Applicabl ) <br /> O_WN,ER/OPERATOR: <br /> 1ff+ Latij ower <br /> (P ease Priv) (Title) <br /> a r Signature) <br /> f �2df <br /> ADDRESS: 6 2-102-10� Gr0 O y'tt <br /> (Mailing Address) <br /> CA glSS2l 9 <br /> f (City) (State) (Zip Code) <br /> + PHONE: ( �) q!5 i- -7 <br /> f <br /> i <br /> EH 23 046 (Revised 08/13/99) Page 9 <br /> i <br />