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J <br />•rr�� tee. . <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 AT QZP7S ���� OG K4_0t S - CA S S^ <br />(Street Address) (Cil') <br />HEREBY AUTHORIZE Cp m P L. % F� rz' C r�'t-- <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: aQk �_ P M <br />(If Applicable) <br />n <br />OWNER/OPERATOR: <br />Please Print) `' (Title) <br />Signature) __ (Dare) <br />ADDRESS: a . 160X SR+S� <br />(Mailing Address) <br />(City) (State) (Zip Code) <br />PHONE: ( S k O ) (2-S9 — 'R�S00 <br />xv� r z t� <br />F <br />Owner Signature 19te <br />EH 23 0=6 (Revised 7/10;96) Page 9 <br />w <br />