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0 <br /> 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 /> • ENVIRONMENTAUSITE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT 401 1Q e5T KE-TTI STA 0 LAO E <br /> HEREBY AUTHORIZE (Stye t ) r� L— c N t - 2 City) Doo <br /> (laboratory or Consultant) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES AS SOON AS TT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE <br /> BUSINESS NAME: 66KCO <br /> (If Applicable) <br /> OWNER/OPERATOR: U�,&,,["lJ�l L Cod cI L_ n6MP^t,�Y <br /> (Please Print) (Title) <br /> \�- J <br /> ( er/Operator Signature) NJ <br /> ADDRESS: 62-ST- <br /> (MailingAddress) l q <br /> �� -U� IVD L4Fc)eAJ /A\ 142- 03 <br /> (City) (State) (Zip Code) <br /> PHONE: <br /> DATE: <br /> EH 23 041 (Revised 7-10-92) Page 9 <br />