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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> (209)468-3420 <br /> AUTHORIZATION TO RELEASE <br /> r ANALYTICAL RESI,'LTS <br /> 'GEOTECHMCAL DATA <br /> " ENV IRON,bMENTAL/SITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER ANDIOR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCA"i'LiD AT <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL IN(+OR.MATION TO SAN JOAQU'IN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: / <br /> (IfApplicabJe) <br /> OWNER/OPERATOR: <br /> _ -- <br /> (pin <br /> Mille) <br /> --x — <br /> mw re) (Date) <br /> ADDRESS - <br /> (Madi g Addrow) <br /> (City) (Shote)' 9*Came) <br /> PRONE: <br /> EH 23 046 (Revised 1124102) <br /> 6 <br />