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0 <br />0 <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DMSION <br />(209)468-3420 <br />AUTHORIZATION TO RELEASE <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT7 (:�<7/0 V)R-T � � LJ�C)R .N�.(� c���� - l JL \ 1,J "Q <br />(Street Address) (City) <br />HEREBY AUTHORIZE S C <br />(Laboratory) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br />HEALTH SERVICES -ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME <br />TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: <br />(If Applicable) <br />OWNER/OPERATOR: At r c) 3E,O \ V _ - ' <br />(Please Print) (7-ttle) <br />n1v (J,. ,, — <br />(Owner/Operator 3gnature) (Date) <br />ADDRESS: —7N\ \ �_ \ N L 2 g3 030 <br />(Mailing Address) <br />IF,�"NL.o L ltA J 4 2. <br />(City) (State) (Zip Code) <br />PHONE: (!� 3 F, - 7_ <br />EH 23 046 (Revised 10/19/98) Page 9 <br />