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SANS6AQUIN 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 OPERATOR OF THE PROPERTY AND/OR <br /> FACILITY/ C <br /> LOCATED AT�7-O=� < �Q m/A Iec-C_ <br /> (Street Addressr1 (City) (� <br /> HEREBY AUTHORIZE �/19r n rg p� —� a yuv. Gi r S - 4 -I <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: 4- <br /> If Applicable) <br /> OWNER/OPERATOR: <br /> (Please Print) (Title) <br /> x 6- � �fo <br /> /Owner/Opera ri-g]natu c (Date) <br /> ADDRESS: 10T 1 Se-r� <br /> (Mailing Addres ) <br /> 1M fl-wfiC CA- 3 <br /> (City) �j (State) (Zip Code) <br /> PHONE: ()-05 ) e 1— 3 <br /> EH 23 046 (Revised 08/13/99) Page 9 <br />