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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 />* ENVIRONMFNTAL/SITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT Lo SCS Lou j s-e— <br />(Street Address) (City) <br />HEREBY AUTHORIZE <br />(Laboratory or Consults ) <br />TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br />HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br />TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: <br />(If Applicable) X <br />OWNER/OPERATOR: <br />(Please Print) (Tule) <br />(Owner/Operator Signature) <br />ADDRESS: 'Z 14 8 �o J v -� r -'i _ 1 ✓� T i -�- Z O W <br />(Mailing Address) <br />GA... g s --I W Z <br />(Cily) (State) (Zip Code) <br />PHONE: i to LP �3 5 - Z L4 L4 " <br />DATE: <br />-t i u, Ci L*- <br />EH 23 041 (Revised 7-10-92) Page 9 <br />