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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 46&3420 <br /> AUTHORIZATION TO RELEASE <br /> ' ANALYTICAL RESULTS <br /> ' GEOTECHNICAL DATA <br /> ' ENVIRONMENTAL/STTE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNEDOPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATEDAT N WEST /I K 57-,er1=T �EWACk ( RI�L�' <br /> (Svea Address) <br /> (City) <br /> HEREBY AUTHORIZE GKN/ I?,,V Vl/LO,UME/✓1Ti►L TGCHNo 0 <br /> (Laboratory or Conrulmnt) <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: THE GLT)l pF /'P-Ae y <br /> (If Applicable) <br /> OWNERIOPERATOR: _ MQ PAUL VF?-MA - <br /> (Please Fraut (Tule) <br /> 2-1 <br /> (Owner/Operator Signature) <br /> ADDRESS: SZD TQ 9G , /3LUD <br /> (Mating Address) <br /> T"(-�/ CA G 376 <br /> (C4) (State) (Zip Cade) <br /> PHONE: ( 7. LFj 1 q 6 — o4z 0 <br /> DATE <br /> (o /Zl Ict3 <br /> EH 23 041 (Revised 7.10-92) Page 9 <br />