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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DMSION <br /> (209)468-3420 <br /> AUTHORIZATION TO RELEASE <br /> * ANALYTICAL RESULTS <br /> * GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> 1, THE UNDERSIGNED OWNER ANMD/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 2-o$ 5 [qsT IAcmo/Jf ` i reef \s7 KTO IBJ 0� <br /> (Street Address) t Ci ) <br /> HEREBY AUTHORIZE Aec)Sinn <br /> (Laboratory) <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: J\70 'G/Ifl, C-ASC/;17 <br /> (If Applicable) v <br /> OWNER/OPERATOR: G CS r — T• OWOEA <br /> (Please Print) I (rile) <br /> G ` _� <br /> (Owner/Operator Sig ) (Dare) <br /> ADDRESS: 2_&% -4/,-MSq(v1 RV N <br /> (Mailing Address) <br /> 57ACK-Tots) C R 952o-7 <br /> (city) (State) (Lip Code) <br /> PHONE: ( 'Z09 ) 47q_ 0`i3q <br /> EH 23 046 (Revised 10/19/98) Page 9 <br />