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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3420 <br /> AUTHORIZATION TO RELEASE <br /> * ANALYTICAL RESULTS <br /> * GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCA'T'ED AT 3 -3 -!5- .r IV. A cL A h .QTc -C A �—o t l <br /> (Street Address) (City) <br /> - HEREBY AUTHORIZE G Z o Q; f t N r, tN [y-�, t--/,,17 <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 /> G V A <br /> BUSINESS NAME: U41 �� r'7v 9, S c-yry i c e s, <br /> (l.f Applicable) <br /> OWNER/OPERATOR: -J'o e. r� 4— <br /> ase } (T11 ) <br /> nerl pp}}erator Signature) ]� ( at <br /> ADDRESS: <br /> (Mail' Address) <br /> - o <br /> (City) (State) (Zip Code) r <br /> i <br /> PHONE: ( } <br /> EH 23 046 (Revised 08113199) Page 9 <br />