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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3420 <br /> I <br /> AUTHORIZATION TO RELEASE <br /> " ANALYTICAL RESULTS <br /> " GEOTECHNICAL DATA <br /> " ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR THE PROPERTY AND/OR FACILITY . C/ <br /> LOCATED AT `- G f_ /QS? 7 d <br /> treet Adds s) (City) <br /> HEREBY AUTHORIZE / <br /> oratory) <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: W <br /> (If Applicable) <br /> OWNER/OPERATOR: -:Dk Wt- X-a4-G o S <br /> (Please Pnnt) (71tle) <br /> (Owner/Operator Sign re) (Date) <br /> ADDRESS: 25 "/ �/ /Ci (L� /, <br /> (Mailing Address) <br /> (City) (State) p Code) <br /> PHONE: <br /> EH 23 046 (Revised 9/11/96) Page 9 <br />