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1 C_ <br /> 1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209)468-3420 <br /> 1 <br /> AUTHORIZATION TO RELEASE <br /> 1 * ANALYTICAL RESULTS <br />' *GEOTECHNICAL DATA <br /> * ENVIRONMENTALISITE ASSESSMENT INFORMATION <br />' I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT E S`C Z Z Z � g 5 <br /> (Street A&ress) (city) <br />' HEREBY AUTHORIZE_ G C Arc Ell, A�u 14 Z1 C.Nl= —_ <br /> (Laboratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> fHEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION AS SOON AS IT IS AVAILABLE AND AT THE SAME <br /> E IT IS PROVIDED TO ME OR MY REPRESENTATIVE. <br /> it <br />' BUSINESS NAME. R y <br /> (If Appltcab ) <br />' OWNER/OPERATOR: j,�U kL%s k11'i 1A C-L <br /> (Please Pratt) (Tule) <br />' (Owner/Operator Signature) (Dare) <br />' ADDRE5SSly i)S(�L1\ tj COLUm�Y �]bLl � 1�U1Z��.5 ._ <br /> (Mailing Address) <br /> (Cary) (State) (Zip Cade) <br /> PHONE. ( & }- Co P - 3 U 22- <br /> EH <br /> 2EH 23 046 (Revlsed 10/19/98) Page 9 <br />