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SAM JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION i <br /> (209) 468-3420 4 <br /> AUTHORIZATION ' TO. RELEASE 'I <br /> * ANALYTICAL RESULTS j <br /> . f <br /> * GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I <br /> 1 <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF,THE PROPERTY AND/OR FACILITY <br /> LOCATED AT J�-`•PN-C b� .E ' <br /> Street Address) (City) <br /> HEREBY AUTHORIZE �5; L YS- D LlmR a ; r I4+� <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL AiNALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> TIME IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> i <br /> BUSINESS NAME: -�► <br /> (If Applicable) <br /> OWNER/OPERATOR: -2- <br /> lease Print) (Title) / <br /> (Owner/Operator Signature) (Date) <br /> I <br /> ADDRESS: <br /> (Mailing Address) <br /> (City) (State) {Zip Code) <br /> F <br /> PHONE:,( } L494 % <br /> EH 23 046 (Revised 9/I 1/96) Page 9 <br />