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P <br /> SA.N JOAQUIN COI r'Y-Y 111IRLIC HEALIIi SERVICES <br /> E.ti'VOtU,�1L%7AL I(EALTH DIVISION <br /> t 2m t 40-3420 <br /> At r•rHf)RIZAlION TO RELEASE <br /> Tank 805—DlUl <br /> •A.tiALYTICAL RFS1.R.TS <br /> °GEOTECHNICAL DATA <br /> -Evv Ro-j,,tE�;7.wsrrE Assmm—rNT INFORMATION <br /> I.THE UNDERSIGNED OWNEM AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATZD AT Uc% w' <br /> (S�rreei Address) (Cue) <br /> HEREBY AUTHORIZE a <br /> CALIFORNIA LABOR QMY cu VICEq <br /> (Laboratory or Cons;ettant) <br /> TO E ANY AND ALL ANALYTICAL INFORMATION TO SAN)OAQULN COUNTY PUBLIC HEALTH <br /> SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROV®ED TO ME OR MY <br /> REPRESENTATIVE. <br /> BUSINESS NAME. L a r n e I iv-rr - <br /> (ljApplitable) <br /> OWNFJUOPERATOR: <br /> fP/eau 20 <br /> (Owner/operator Sienuture) C S <br /> ADDRESS: 2('01 Facr Ave 20 RB—+- <br /> (Moiling Address) <br /> •y 45( <br /> (Cin.) fStote) (Zip Code) <br /> PHONE: 0121 421-6S72 <br /> DATE: <br /> EH 23 041 (Revised 7/10)92) <br /> 9 <br />