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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <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 16 V65- A,,rD <br /> (Street Address) pp /� (City) <br /> HEREBY AUTHORIZE Jrc 6,5 b-6 YGN�iG 4f, <br /> (L4bqKatory 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: �;,/L//4 7�0,1A1C, :R/C, <br /> (If Applicable) <br /> OWNER/OPERATOR: ✓,gyld <br /> (Please Print (Title) <br /> (Owner/Operator Signature) <br /> ADDRESS: D 11 9 64-1 <br /> (Mailing Address) <br /> .S7C;.!5,k L C�S � Uy <br /> (City) (State) (Zip Code) <br /> PHONE: ( 09 <br /> DATE: Z- el gt/ <br /> EH 23 041 (Revised 7-10-92) Page 9 <br />