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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 a9ba3 S . 7F-kt`( a—• , � CP 95 ) � <br /> (Street Address (City) <br /> HEREBY AUTHORIZE S �✓)C — <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: MOMUFAL- N9,2027 <br /> (If Applicable) b <br /> OWNER/OPERATOR: �� lJbUt4UPikU NVKI C'iUY S�N� <br /> (Please Print) (Title) <br /> x <br /> (owner/Operator Signature) <br /> ADDRESS: <br /> (Mailing Address) <br /> ��Y , CPQ °1316 <br /> (City) (state) (Zip Code) <br /> PHONE: <br /> DATE: <br /> EH 23 041 (Revised 7-10-92) Page 9 <br />