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qkJOAQI TIN COUNTY PIJBLIC HEALTH S ES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209)46X-3420 <br /> AUTHORIZATION TO RELEASE <br /> Tank 879—G2U1 <br /> •ANALYTICAL.RI:SI Q:TS <br /> •(;L'0 I1:('IINICAL DATA <br /> •EN V IR()NMEN I'AI JS I*1 :ASSESSMENT INFORMATION <br /> I.THE I TT)ERSIGNED OWNI:R AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT Hollow Hilad,f'; w „' <br /> (Street Addre o (City) <br /> HEREBY AUTHORIZE (- IA ��'► Staw(Ct 5 <br /> ILcthnrutru%•for Crnt.ptlkt►UI <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMA'CION TO SAN JUAQUIN 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: w v <br /> (IfApplicable) <br /> OWNER/OPERATOR: <br /> I use rift) (Title) <br /> gMOtW moi. f®wtA 6C. \.� c <br /> (Owner/Operubw Signature) <br /> ADDRESS: <br /> (Mailing Address) <br /> .v r, tSO <br /> (Cite) (State) (Zip Code) <br /> PHONE: <br /> DATE: <br /> EH 23 041 (Revi%ed 7/1(V92) <br /> 9 <br />