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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-342.0 <br /> AUTHORIZATION TO RELEASE <br /> * ANALYTICAL RESULTS <br /> * GEOTECHNICAL DATA <br /> * ENVIRONMENTALJSITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT " 3� t0llc12lC� t7 ' CSCr�.'] !�� , r 1 2.C� <br /> (Street Address) f (City) <br /> HEREBY AUTHORIZE 1�i�` t-1 ,l�I i<—, <br /> (Laboratory or Consultant) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: 7 kfj tLIIl 61614 6111- <br /> r (If Applicable) ,,rr /� /1 <br /> OWNERIOPERATOR: �/ t<a'rylcl,2- lt,<- /o I'tZ 14V9C1 <br /> (Please Print) (Title) <br /> (Owner/ perata <br /> ADDRESS: �5 2 5 � J <br /> (Mailing A�(dress) <br /> 10 <br /> {City) (State) (Zip Code) <br /> PHONE: <br /> DATE: 'V/7/7-2-- <br /> EH <br /> /7 Z--EH 23 041 (Revised 7-10-92) Page 9 <br />