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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DMSION <br /> (204) 468-3420 <br /> AUTHORIZATION TO RELEASE <br /> • ANALYTICAL RESULTS <br /> 3 <br /> • GEOTECHNICAL DATA <br /> ' ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACIL= ' <br /> LOCATED AT <br /> ( et ds) (City) <br /> HEREBY AUTHORIZE <br /> (Laboratory or Consultant) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND ATTHE SAME T04E IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE. I <br /> BUSINESS NAME: n-t_ <br /> (If Applicable) <br /> OWNER/OPERATOR: <br /> (Please t (Title) <br /> I <br /> (Owner/Operator Sig//natu / <br /> ADDRESS: 1 X <br /> (Mailing Address) I <br /> (City) -7 (State) (Zip Cade) <br /> PHONE: (2-&� } <br /> DATE: <br /> APR Q 7 199: <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br /> EH 23 041 (Revised 7-10-92) Page 9 <br /> t ` <br />