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PUBLrC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY ? <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer ., <br /> P.O. Box 2009 • (1601 East Hazelton Avenue) • Stockton, Callfomia 95201 <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 UNDERSI/GNED OWNER AND/OR OPERATOR OF THE PROPERTY A/N�D�/OR FACILITY <br /> LOCATED AT (vb4Z /[E�"WA) 4A)( 5 CGLJ/ C:6t <br /> Street Address) (City)/� <br /> HEREBY AUTHORIZE YOy F WEZNLXJ �C'� GF STLIC�TL l � t A <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: 'B E &1210-014V-FA(- <br /> IfICE <br /> ( Applicable) 2 /J <br /> OWNERIOPERATOR: VL)P-r Nru r"rq I ICp(t�1T &IF <br /> (Please Print) (Title) <br /> 4w / —�1 <br /> (Signature) <br /> ADDRESS: PIC). —&x 2t))D5q <br /> (Mailing Address) <br /> &oc-K-R"1 0A 9'524/ <br /> (City) (state) (zip code) <br /> PHONE: ( Z04 ) 6-47- 2&,50 <br /> 111FDATE: 4-4-91 <br /> EH 23 041 (REV 2/8/91) wp Page 9 <br /> A Division of San Joaquin Counry Health Care Services <br />