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c1 IVU VVL r VL <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> • ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-7420 <br /> AUTHORIZATION TO RELEASE <br /> • ANALYTICAL RESULTS <br /> • OL"OTECIINICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> 1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR <br /> I1 FACILITY <br /> LOCATED AT � W¢ta $>e Qk V. 4 AV.( MPwI-�CLt <br /> Sneer Addrelt) .y� (City) <br /> HEREBY AUTHORIZEo-><{ <br /> ((aboratery) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT 15 AVAl1.ABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: >`!�F FI �r sys tcr, , -rk c. <br /> /' (tFdpplicablt) -- r — <br /> OWNERIOPERATOR: _ c4 s-$ [JFO t.srf pr✓ ��` �.,� ,'n e e r <br /> (Pleasr Print) (Mlle) <br /> (Owner/Operator Signature) (Dart) <br /> ADDRESS: _ P. P. UnQ X __— <br /> (Mailing Addresr) <br /> Fent -s ; ti A9 729r 7 - oo�t S— <br /> (City) (State) (Zip Code) �^ <br /> PHONE: ( SDI ) 7 ,5-6- 6-63 9 <br /> EH 23 046 (Revised 9/11/96) Pnbc 9 <br />