Laserfiche WebLink
PUB16C HEALTH SEWICES <br />SAN JOAQUIN COUNTY <br />JOG[ KHANNA M.D., M.P.H. <br />Health Officer <br />110. Box 2009 • (1601 East Hazelton Avenue) a Stockton, California 95201 <br />(209) 468.3400 <br />ENVIRONMENTAL HEALTH DIVISION <br />(209) 468-3427 <br />AI1-I1I0RIZATION T6 RELEASE <br />ANALYTICAL RESULTS <br />• GEOTECHNICAL DATA <br />ENVIRONMENTALISITE ASSESSMENT INFORMATION <br />1. THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />I t CATED AT 3 S - -Sc <br />Address) <br />FIFRFRY AU'IFIORIZE <br />(Laboratory or Consultant) <br />'It) RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br />I IPALTH SER VICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br />TO P/IF. OR MY RF.PRF.SENTATIVE. <br />RUSINESS NAME: <br />(If Applicable) <br />OWNER/OPERATOR: L% Lgr (d y 7t/ ✓v 4! ✓Y <br />(Please Print) (Title) <br />(Signature) <br />ADDRESS: . 2,1(� S ii A D C t. <br />(Mailing Address) <br />�on/r rk !?` ;r <br />(City) (state) (zip code) <br />72�u <br />HATE: <br />r11 zz rntt (REV 2;9/01) wp <br />Page 9 <br />A Divkion of San Joaquin Countj Health Care Serricn 0 <br />