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SAN JOAQ UIN 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 />LOCATED AT 13 l7 j W, k er LO D t , G Cl S�4 z <br />(Street Address1 (City) <br />HEREBY AUTHORIZE GLS LAB S <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 />BUSINESS NAME: FL^M 6- L (CkVO(Z-S- <br />(If Applicable) <br />OWNER;OPERATOR: ?eTf c'T4t,%` Y F (`a/Net 0W1VE1� <br />(Please Print) (7itle) <br />ADDRESS: <br />/ 3a <br />(Date) <br />i 3t>i W Ke71r&em,%%) L -N <br />(Mailing Address) <br />Cool GAr 15 -z -1-C) <br />(City) (State) (Zip Code) <br />PHONE: (�J) 334-3233 <br />EH 23 046 (Revised 7/10/96) Page 9 <br />