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PUBLIC HEALTH SERVICES 'opQUly <br />SAN JOAQUIN COUNTY =` ? <br />Q: <br />N: < <br />JOGI KHANNA M.D., M.P.H. <br />Health Officer <br />P.O. Box 2009. (1601 East Hazelton Avenue) .Stockton, California 95201 <br />C'�lFORN�P <br />(209) 468-3400 <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 <br />11 <br />Street Address) (City) <br />HEREBY AUTHORIZEL- O A A/24 L X Tl C A L 1 A b' s <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 AT THE SAME TIME IT IS PROVIDED <br />TO ME OR MY REPRESENTATIVE. <br />BUSINESS NAME: MP rr vC t o+e— -- Met' i S <br />(If Applicable) Q A ,t,� <br />OWNER/OPERATOR: e, P <br />C e" A4D r I S <br />(Please Print) (Title) <br />ignat <br />ADDRESS: , Q r U X 3%2 <br />(Mailing Address) <br />(City) (State) (zip code) <br />PHONE: ( .209 <br />11 DATE: — 2 I <br />EH 23 041 (REV 11/7/90) wp Page 9 <br />A Division of San Joaquin County Health Care Services <br />