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•l <br /> U002 " <br /> { r,11it1$;'9�1 16:77 FAX 417 <br /> PUBLIC HEALTH SERVICt , �� , <br /> SAN jOAQUIN COUNTY <br /> F <br /> JOGI MANNA M-O,M.P,H. .: <br /> � Hesi[hOlficet 'r• . •. .. <br /> 'CJeo'a'' <br /> i?O. 13vx 2009 (16)01 East HszchOn Avcnuc) . Stc,cktvn,C:,li[nrnia 95201 <br /> + (209) 468.3400 j <br /> ENVIRONMENTAU HEALTH DIVISION <br />' A1..,'r'HC! F2 I z AY x ON TO L—E5- <br /> ANALYTICAL <br /> 5-ANALYTICAL RESULTS <br /> 'GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> the date which will bo col.ie�ted an 140vembet 9of , 1990•;' # ��'} <br /> I I, THE Ll1+101»fZSIGN>sI7 OWNER �� t <br /> duritt a subsurf�c.e i.nves'ti.gation of the property { <br /> LOCAED AT - G n1 c Rofld ar�d qi hwv 12 L,cdl Cali.l arnia <br /> (STREET ADDRESS) "'^""fCI.T Y.1 <br /> HEREBY AUTHORIZE irQnrne r.al Con4tilL•a[its Inc. <br /> (LAFORATORY or CONSUL 7'ANT) E %• <br /> TO RELEASE RNY ANIS ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR. ► <br /> . ENVIRONNMENTAL/SITE AS5ESSMENTI. INFORMnTION TO SAN ICAGUIN COUNTY PUBLIC <br /> HEALTH SLRV I CES AS SOON AS I7`J 15 Au A ILABL E AND AY THE SAME TIME 11 IS { <br /> PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: �T <br /> i(I F ,4PPL I CARL E I <br /> p4iNER/OPERA�ORi f r c- <br /> t PL EASE PR' T.1 <br /> eSIGNATURE1 ' <br /> E � r <br /> ADDF !^S5 t ?.O. Box 4023 <br /> ?MAI L jNG,'ADDREc SJ ti <br /> t- o <br /> Concord � � Ca l.�1 o r ni a 94524 � <br /> r rrrl (SrQTEr (ZIP) <br /> _675-6124 - <br /> l <br />