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PUBLIC HEALTH SERVICES <br /> aPO,U IN <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.D.,M.P.H. S ` <br /> Health Officer <br /> P.O. Box 2009 . (1601 East Hazelton Avenue) a Stockton,California 95201 +r eoav' P <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 /> 1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT ��0� 4-,- - /�7�NT `577 _6�l <br /> (Street Address) (city) <br /> HEREBY AUTHORIZE .��rz �jl�s' sT�1G�i�Zj(d <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: <br /> (/j p 'c le) <br /> OWNER/OPERATOR: <br /> ( ase 'nt) (Title) <br /> (Signature)) <br /> ADDRESS: <br /> (Mailing Address) <br /> �QC.�TQ/f/ <br /> (City) AA (State) (zip code) <br /> PHONE: (��) <br /> DATE: <br /> EH 23 041 (REV 2/8/91) wp Page 9 <br /> A Division of San Joaquin County Health Care Services <br />