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SAPOAQUIN COUNTY PUBLIC HEALTH SICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3420 <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 4 p cep WEST LANE 5-Tmc14TbN <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE C-C -kn&,Rgty '&'wio<:XL _ <br /> (La 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: 'pc=4 TOC .TON SEP V ICS �,'C'EQ <br /> (If Applicable) <br /> OWNER/OPERATOR: �ONAaTtlOe�1 C-� PFoRfZ F .�.T MAR1ACs�Q <br /> (Please Print) ('Title) <br /> ( wner/Operator Signature) (Date) <br /> ADDRESS: Re-) . '60X <br /> (Mailing Address) <br /> s� .mCAIsco CA. q4t 2.a <br /> (City) (State) (Zip Code) <br /> PHONE.: ( 4%5 ) 9g 3 - -r r7d A <br /> EH 23 046 (Revised 08/13/99) Page 9 <br />