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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 /> * GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOROFTHE PROPERTY AND/OR FACILITY <br /> LOCATED AT "�7 � J)Q6t I VV\ �t� 1 Yz <br /> ^ reetA rens (C�0.) <br /> �HEREBY AUTHORIZE e- <br /> (Laboratory)(Laboratory) 5 <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: <br /> P <br /> OWNER/OPERATOR: <br /> (Please Print) (title) <br /> (Owner/Operator Signature) (Date) <br /> ADDRESS: Q. (), bjjX L V / D,- <br /> (Mai&ng Addfess) <br /> (City) 1 (State) (7p Code) <br /> PHONE: ( ) �7 9 3 <br /> EH 23 046 (Revised 9/11/96) Page <br />