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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209)468-3420 <br /> AUTHORIZATION TO RELEASE <br /> • ANALYTICAL RESULTS <br /> • GEOTECIINICAL DATA <br /> • ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> 1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT QL <br /> neer dress (61y <br /> IIEREBY AUTHORIZE 4 ot h s <br /> (Inbaratory or Consultant) <br /> TO RELEASE ANY AND ALL A ALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> IIEALTII SERVICES AS SOON AS IT IS AVAILABLE AND A'I' TIIE SAME TIME IT IS PROVIDED TO <br /> ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME : _yAor 14 4 <br /> (UAhn cn e) <br /> OWNER/OPERATOR: <br /> Pl ase 'nt) (Title) <br /> (Owner/Operator Signature) <br /> ADDRESS: 011,zam 1()� ciryir <br /> (Mailing Address) <br /> 01i4 �F <br /> (City) ( ) pup <br /> PHONE: <br /> DATE: <br /> Pape B <br /> EN 23 041 (R".. d7-1042) <br />