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ENVIRONMENTAL HEALTH DEPARTMENT <br /> SAN JOAQUIN COUNTY <br /> 17-� �=C s <br /> J <br /> Telephone: (209) 468-3420 Fax: (209) 468-3433 • <br /> OCT 2 9 2014 <br /> AUTHORIZATION TO RELEASE <br /> ENVIQMM�NTAL HEALTH <br /> *ANALYTICAL RESULTS DEPARTMENT <br /> *GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY LOCATED AT <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> X (Cabo <br /> ratory) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED TO ME OR MY <br /> W <br /> REEPRESENTATIVE. <br /> BUSINESS NAME- ( ( 5- <br /> v (If AAp�plicable) n <br /> X OWNER: `Jy 7` � D� ®1T 7yi &k m �}/� /✓) P 1, <br /> (Please Print) ('Title) <br /> I` <br /> 16- k--1-2 <br /> (Owner Signature) (Date) <br /> ADDRESS: <br /> (Mailing Address) <br /> (City) (State) (Zip Code) <br /> PHONE:( ) <br /> EH 23 046 (Revised 07/21/10) <br /> 6 <br />