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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 Z.4 v S I /OuTt-� McJ u,v T'.(-t N �:j l,. 7/�R-1t,.J'F'( I ✓L,/.4.G`S <br /> (Street Address)�t�' I — (City) <br /> HEREBY AUTHORIZE {�J_ ♦(7oarA r LAsyrzAyletES <br /> (Laboratory) <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: <br /> (If Applicable) p <br /> OWNER/OPERATOR: �1 AKN t t1 L IkL O�y'Q S �N io l ENV 1- 144,15 <br /> 4(Please Print) � (Title) <br /> (Owner/Operator Signature) (Date) <br /> ADDRESS: 3 7'� Uf. W t& T `"SNI' <br /> (Mailing Address) <br /> (City) (State) (Lip Code) <br /> PHONE: ( RZS ) -74+- �(� S <br /> EH 23 046 (Revised 08/13199) Page 9 <br />