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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer <br /> P.O. Box 2009 a (1601 East Hazelton Avenue) 0 Stockton, California 95201 <br /> q 64t <br /> (209) 468-3400 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3427 <br /> AUTHORIZATION TO RELEASE <br /> ` ANALYTICAL RESULTS <br /> ' GEOTECHNICAL DATA <br /> • ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNpED OWNER AND/OR <br /> l-lV,AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT d dO. GOf1�(A QT- SyOC�C-miji CA, gsaDh <br /> Street Address) (City) <br /> HEREBY AUTHORIZE 1L O I tJA L V )7 CAL- LOG , <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: ,-�p H tJ -Ir <br /> fl Y w 6?- 'Rk T I L\ ZE V, <br /> —� //��(If Applicable) <br /> OWNERIOPERATOR: '4TEU 9th SER <br /> (Pleas t) (Title) <br /> Si ture) (�p <br /> ADDRESS: <br /> (Mailing Address) <br /> s)-Q0- r� Cry , 9sao � <br /> (City) (State) (zip code) <br /> PHONE: (o oq ) c14 U <br /> DATE: q �IiO <br /> EH 23 041 (REV 2/8/91) wp Page 9 <br /> A Division of San Joaquin County Health Care Scrviecs <br />