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SAN JOAQI SIN COUNTY PUBLIC HEALTH SERVICES 00(1186 <br /> ENWIRONIvtENTAL HEALTH DIVISION <br /> (209)469-.1420 <br /> AI tTFtOKl7-ATION TO RELEASE. <br /> Tank 879—GlUl <br /> *ANALYTICAL KISI ILTS <br /> *t.L'O11.1 1 INICAL DATA <br /> *ENVIR()NMEM'AIISTII:ASSFSSMF.Nf INFORMATION <br /> I.THE INT)ERSIGNEI)OWNER A.`D/OR OPERATOR OF THE PROPERTY A.YD/OR FACILITY <br /> LOCATED AT Comd Hothm Road,(m% w �. (. . . <br /> r Grvvt ArLlrv�r► (Cit}'1 <br /> LAEanATLotm 19L <br /> HEREBY AUTHORIZE CP l.1�olt)a lA <br /> 1L ilwrutr)n.or Con.uiltunt) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC HEALTH <br /> SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR MY <br /> REPRESENTATIVE. <br /> BUSINESS NAME: vv - <br /> QfApplirahlO <br /> OWNER/OPERATOR: Lam;arc. Pk:a,n i)wner <br /> (Please Print ' (Ti <br /> (Owner/Operubw Signature) <br /> ADDRESS: 7 Fast1 <br /> (Mailing Address) <br /> ivrmuxt 511 <br /> (carr) (State) (Zip Code) <br /> PHONE: (11W 421-�SJ7 <br /> DATE:— ( <br /> EH 23 041 (Revised 7/1(V/92) <br />