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0 c r <br /> PUBLIC HEALTH SER _ <br /> o�tiM.!N <br /> s <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Offi cr [� 11 (; g <br /> P.O. Box 2009 . (1601 East Hazelton Avenue) . Stockton,Califprni W2JP'l e��ictin~ ' <br /> (209)468.3400 <br /> ENVIRONMENTAL <br /> i4 P <br /> PERMIT �J� <br /> ISE.RVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 469-3420 <br /> A U—r H C3 R I Z F4 T I C3 N T C3 R E L E A S E <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 1745 2nd Street Escalon, CA Ty) <br /> HEREBY AUTHORIZE Water Work pCoroESS710 18ain St. , Escalon, CA 95320 (209) 838-3507 <br /> _ (LRBORPTORY or CONSLILTANT) <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS <br /> PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: <br /> (IF APPLICABLE) <br /> OWNER/DPL.. Robert M. Brayton <br /> EASE PRINT) (TITLE) <br /> (SIGNATURE) <br /> "' <br /> ADDRESS: P. 0. Box 95 <br /> (MAILING ADDRESS) <br /> Escalon CA 95320 <br /> (CITY) (STATE) (ZIP) <br /> PHONEt _( 209 ) 838-7388 <br /> DATE <br /> EH 23 041 Revised 10/99 <br /> A Division of San Jo,quin Gwnry HNhh Cn.Seri`.a r"�t <br />