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0 0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUN'T'Y <br /> Telephone: (209)468-3420 Fax: (209) 468-3433 <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 FACILITY <br /> LOCATED AT -7 c ,AVE SrOC r-TOJ\1 CA q SZ o <br /> (Street address) (City) <br /> HEREBY <br /> AUTHoRIzE AS SnC 1-ATG A 606 mere BC1C0LV i A OrkRn a GA qM 6 8 <br /> (Labs atory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: S;-$ ! pLl-F�q" %A-- QArs LL-�-A <br /> (If Applicable) -- <br /> OWNER/OPERATOR: C*P—%S �-, WA1-T " CU �1lcq�K <br /> (Please Print) (Title) <br /> ---- <br /> OML_ 9l- , be f o�-/a 7 <br /> (Owner/Operator Signature) (Date) <br /> ADDRESS: 1311f Tm 9N � 11a <br /> (Mailing Address) <br /> S,r-f�TA--FP— W4N(;S CA- ctoG 70 <br /> (City') (State) (Zip Code) <br /> PHONE: SG2 ) q2_1 — 11 <br /> ;78 } O <br /> EH 23 046 (Revised 11/21/06) 9 <br />