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SAN JORQUIN COUNTY PUBLIC HEALTH SER-VICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (709) 468-3470 <br /> AUTHORIZATION TO RELEASE <br /> • ANALYTICAL RESULTS <br /> • GEOTECHNICAL DATA <br /> • ENVIRONMENTAUSITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 303 S. Cherokee Ln. Ldi, CA 95240 <br /> (l <br /> �je41 Address �n t 1 1- (CiIY) <br /> HEREBY AUTHORIZE am �� e_ M i 1 1 U ) c- !J <br /> (Laboratory or Consultant) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: <br /> (If Applicable) <br /> OWNER/OPERATOR: L L L' y c <br /> (Please Print) (Title) <br /> (Owner/Operator Signature) <br /> ADDRESS: 13 1 R i r h Ll o r; c --70 f" i ✓e <br /> (Mailing Address) <br /> Loci 4-o <br /> (City) (State) (Zip Code) <br /> PHONE: <br /> DATE: <br /> R��V o c k Is ,I s,I <br /> EH 23 041 (Revised 7-10-92) Page 9 <br />