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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 /> • OEOTECHNICAL DATA <br /> • ENVIRONMENTAUSITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT <br /> Street Address) (City) <br /> HEREBY AUTHORIZE <br /> Laboratory or Co ) <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 /> ear...._ <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: jP,�iNT <br /> (If Applicable) <br /> OWNER/OPERATOR: ��� <br /> (Please Print) <br /> (O ner Aerator Signature) <br /> ADDRESS: /Dz/ S� <br /> '(Mail g Address) <br /> 41VS.4-5 �, T,r� JX o 6 y113 / <br /> (City) (State) (Zip Code). <br /> PHONE: <br /> DATE: <br /> EH 23 041 (Revised 7-10-92) Page 9 <br />