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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 C� I �t1 rut I � �� �(City)t P <br /> (Street Address) <br /> HEREBY AUTHORIZE <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: t c C z A e j ' 1 ' c < e� <br /> (If Applicable) <br /> OWN R/OPERATOR: \2telN � � <br /> F Title <br /> �. (Please Print) (Title) <br /> (Owner/Operator Signature) <br /> ADDRESS: <br /> (Mailing Address) <br /> (City) (state) (Zip Code) <br /> PHONE: <br /> DATE: <br /> �,- <br /> EH 23 041 (Revised 7-10-92) Page 9 <br />