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FROM 6RNY.5 � C4. <br /> ' SAN JOAQUIN COUNTY PUBLIC fiEALTH SERVICES <br /> ENVIRONMRNTAL RV LTH DIVISION <br /> (?09) 46$-34= <br /> AUTHORIZATION TO RELEASE <br /> f ANALYTICAL MOLTS <br /> OF -CHNI('.AL DATA <br /> • ENVIRONMENTAUSME ASSOSMENT INFORMATION <br /> I, <br /> THE UNDERSIONED OWNER ANDIOR OPERATOR oi'-Din !'ROPE=RTY AND/OR FACIL!`I'Y <br /> LOCATED AT S c' ic- <br /> HERM AUTHORIZE (Street A(tdress} ( ) <br /> (1+al onuory of cof <br /> To RELEASE ANY AND ALL ANALYMAL INFORMA'I'I�?N TO SAN JOAQUIN COUNTY PUBLIC <br /> ' HEALTH SERViC AS SOON AS IT IS AVAILABLE AND AT THE$AME-"GIME IT IS PROVIDRD <br /> To M$OR IY R$?MW4TATl E. <br /> BUS24M NAME; ._„--, ���opQo-,J ��' � 1��t I <br /> ' (IjAppticabf�} <br /> O WNI1RIOpSRA'C�CIR� xI _ ,�+ f;U t x' <br /> ' (Please !) r (Did) <br /> ' � rf�p�ra�er Slgnt�turc} <br /> (Adaflizg.�ddretr) <br /> Ply) (sidle) (Zip Conde) <br /> PHONE- <br /> DATE- <br /> SH <br /> HONE;DATE- <br /> SH 23 041 (Revliad 7-10.92) Page 9 <br />