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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 UNDERSIGNED41511 <br /> OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 4 S l I Ave, <br /> (Street Addres ) (City) <br /> HEREBY AUTHORIZE ( TCfi�� ty\v�ro n men+a.( (Ci <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 /> 1 <br /> BUSINESS NAME: Q C I t1 !► ( r1 I " Cl-�-� '�- 6 aS <br /> I� (!fJApplica le) �1 <br /> i OWNER/OPERATOR: ( ('5 to 0.0,6 rE-�4L 01�2 55 O(t�n 2r <br /> (Please Print) (Title) <br /> (Own- ato Signatu <br /> r <br /> e) (Date) <br /> ADDRESS: 45 <br /> (Mailing Address) ^ <br /> CA <br /> (Ciry) (State) qip Code) <br /> PHONE: )-Oq ) "r�3 - 11 17 <br /> i <br /> I <br /> EH 23 046 (Revised 08/13/99) Page 9 <br />