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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> Telephone: (209) 2 Fax: (2 09) 3433 <br /> AUTHORIZATION TO LEASE <br /> *ANALYTICAL RESULTS <br /> *GEOTECHNICAL DATA <br /> * <br /> ENVIRONMENTALISITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT W) �rQ n �F�� `;i r I e :td Gy n <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> a � <br /> (Lr ry) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: tQ e&A -JU/�, Inc <br /> (1f Applicable) <br /> OWNER/OPERATOR: <br /> &Tetc�p-,4 <br /> t <br /> (PI a Print) (Title) <br /> z C�,R� q - <br /> 70--07 <br /> ( er/Operator Signature) (Date) <br /> ADDRESS: !�y�e, 150w, m s f,,c t ted <br /> (Mail�ess) <br /> C Q& gs851-W 2- <br /> (00) (State) (Zip Code) <br /> PHONE: <br /> EH 23 046 (Revised 8/4/06) <br /> 4 <br />