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-94w)JOAQUIN COUNTY PUBLIC HEALTH/ tVICES <br /> ENVIRONMENTAL HEALTH DrVISIeFi <br /> (209) 468-3420 <br /> AUTHORIZATION TO RELEASE <br /> i <br /> F <br /> * ANALYTICAL RESULTS <br /> + GEOTECHNICAL DATA <br /> • ENVIRONMENTALISITE ASSESSMENT INFORMATION <br /> i <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 103C> 5, 01,1vie- AVE SoC�r�� <br /> (Street Address} (Ciry) <br /> HEREBY AUTHORIZE CLS 0\6S <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 /> f <br /> BUSINESS NAME: ,221 5`Cd ET-5 <br /> (If Applicable) <br /> OWNER/OPERATOR: m I Kc=- C. /�-���►( D ( r+'1 +�G L <br /> le Pri (Tule) <br /> ?.S <br /> (Owner/Operator Signarure) (Date) <br /> ADDRESS: 45�� EN��1Rj2 r5� 5T <br /> (Mailing Address) <br /> A-emclorr CIF 9 53$ <br /> --- <br /> (city) (State) (Zip Code) <br /> PHONE: <br /> r <br /> Owner signature ate <br /> EH 23 046 (Revised 7/10/96) Page 9 <br />