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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> (209)46X-{420 <br /> AUTHORIZATION TO RELEASE <br /> * ANALYTICAL RESULTS <br /> *GFOTF('NNI('AL, DATA <br /> * ENVIRONMENTAUSITF ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THF PROPERTY AND/OR FACILITY <br /> L(K'ATED AT <br /> (Street Address) (Cin,) <br /> HEREBY AUTHORIZE <br /> (Laboratoq) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JO AQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THI' SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: <br /> Ul Applicahle) <br /> OWNER/OPERATOR: <br /> (Please Print) t Dile) <br /> (Owner/Operator Signature) (Date) <br /> ADDRESS: <br /> (Alailin;;Address) <br /> (Citi) (State) (7_ip Code) <br /> PHONE: ( ) <br /> EH 23 046 (Revised 1/24/02) <br /> I <br /> 6 <br />