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41 <br /> 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 (� (Street Address) �i�(CuyF , 'o �,)i� .moi '0� <br /> HEREBY AUTHORIZE ''iV,A-,:!< /) L ' 4f. l Yr_`. <br /> (Laboratory or Conmm tune) , <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: <br /> (if Applicable) <br /> 1 <br /> OWNER/OPER TOR: . <br /> L (Please Print) (Title) <br /> (Owner/Operator Signature) <br /> ADDRESS: Z O — � W l l/t� <br /> (Mailing Address) <br /> aCe (; <br /> (City,) (State) (Zip Code) <br /> PHONE: C0,0� �3�' 22 q <br /> EH 23 041 (Revised 7-10-92) Page 9 <br /> I �1 <br />