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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALm DIVISION <br /> • (209)468-3420 <br /> AUTHORIZATION TO RELEASE <br /> • ANALYTICAL RESULTS <br /> GL-OTECIINICAL DATA <br /> • ENVIRONMENI'AUSITL ASSESSMENT INFORMATION <br /> I THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY ANDIOR 17ACILITY <br /> LOCATED A7 �..._ Q�'L._ Q�Qt►,+��'t, L-1- ....... ,. mot+-b C <br /> Street Address) � f ory) <br /> HEREBY AUTHORIZE Sl'ala.^ _y�+/o,annr a. <br /> ■ r- <br /> ((A6oratorX) <br /> 70 RELEASE ANY AND ALL ANALYTICAL INFORMATION ZO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT 15 AVAILABLE AND AT THE SAME- <br /> TIME IT IS PROVWED TO ME OR MY REPRESENTATIVE <br /> BUSINESS NAME 1"I <br /> OWNERIOPFRATOR Gtis.: 13k wvI_ _ i-r e� !,D i.� e•G r <br /> (Please Perm) mae) <br /> f0wirtcr/Opemlar-Signature) (Dare) <br /> ADDRESS _ P-o ff X e?4 --- -w <br /> (Adcultn,q Address) <br /> Avk t S y.,,- ti y 72-91 7 - UG-,t <br /> fcay) {State) {Zrp Code) <br /> PHONE ( !1/ 7 <br /> EH 23 040 (Rrv,scd 4/11/96) Paye 9 <br />