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SAN JOAQUIN COUNTY PUBLIC HEALPH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3420 <br /> AUTHORIZATION TO RELEASE <br /> " ANALYTICAL RESULTS <br /> • GEOTFCHNICAL DATA <br /> " ENVIRONMENTAL/SITE 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 CSCSc- / _ -sx j4 nrnt <br /> (laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL 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 /> BUSINESS NAME: <br /> (If Applicable) <br /> OWNE OPERATOR: kNi c rFtff== � <br /> (Please Print) C � (Tirle) <br /> (Own r/��O//perator Sig� Luu a (Date) <br /> / � <br /> ADDRESS: jeIQ OLaA LL- C UR �`r <br /> (Mailing Address.) �+ � <br /> (City) (State) CZip Fade) <br /> i <br /> PHONE: ( eo9 <br /> EH 23 046 (Revised 10/ 19198) Page 9 <br />