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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209)465-3420 <br /> AUTHORIZATION TO RELEASE <br /> *ANALYTICAL RESULTS <br /> *GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT NFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT �7 ,�L�• / jib l Q/U � 'Gj �Q�, F �Q <br /> (Street Address ,/ +�r (City) <br /> HEREBY AUTHORIZE �� // 9 f C-�9 <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFOR fATION TO SAN JOAQUIN COUNTY PUBLIC <br /> 7 <br /> HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> a <br /> r <br /> TIME IT IS PROVIDED TO ME OR MY KEPI2ESENTATIVE. z <br /> I <br /> x <br /> BUSINESS NAME: /TIS l /G' j <br /> (if Applicab(2) <br /> OWNERIOPERATOR: <br /> (Please Print) (Title) <br /> (Owner/Operator Signat rr (Date) . <br /> ADDRESS: <br /> I <br /> (Mailing Address) <br /> (City) (State) (2"ip Cade) <br /> PHONE: ( 7 ,92 ) g O 3 8-5 -611-5 <br /> EH 23 046 (Revised 08il3/99) Page 9 <br /> Ed Wd9®:90 baaE TO 'add ZS8T-892 SCE : 'ON Xad 'ONI `DID EddOHl WIt WOdJ <br />