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PUBIC HEALTH SEIVICES <br /> SAN JOAQUIN COUNTY ' <br /> JOGI KHANNA M.D.,M.F.H. <br /> Health Officer <br /> P.O. Box 2009 • (1601 East Hazelton Avenue) • Stockton,California 95201 <br /> C4CIFpR�`P <br /> (209)468-3400 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 465-3427 <br /> AUTHORIZATION TO REY:FASE <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 J r4q&7/ <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE 64Eb Il/ �-/�.4f z— i3X. <br /> (Laboratory or Consultdnt) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION T{45AN 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) <br /> OWNER/OPERATOR: 1911 �f✓ <br /> (Please Print)/ (Title) <br /> (Signator ) <br /> ADDRESS: c �4. J , /� "Vt <br /> (Ara'I g Address) <br /> ty) (state) (zip code) <br /> PHONE: lelci <br /> EH 23 041 (REV 2/8/91) wp Page 9 n <br /> A Division of San Joaquin County Health Care Serviccs <br />