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NT Y <br />I E■®■ L HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />AUTHORIZATION TO RELEASE <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTAL/SITE ASSESSMENT INFO /104k <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PR ER NAC TY LOCATED AT <br />V(Street Address) ( ' <br />HEREBY U <br />(L ry <br />TO RELEASE ANY AND ALL ANALYTI L ON O SAN JOAQUIN COUNTY ENVIRONMENTAL <br />HEALTH DEPARTMENT AS SOON AS IT A IL E AN T THE SAME TIME IT IS PROVIDED TO ME OR MY <br />E ATIVE. <br />BUSINESS NAME: <br />A11,11 <br />(Please Print) (Title) <br />1XIAO/ <br />(Owner Signature) (Date) <br />ADDRESS: <br />(Mailing Address) <br />(City) (State) (Zip Code) <br />PHONE: ( 1 <br />EH 23 046 (Revised 07/21/10) <br />I <br />