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i i <br /> PUBLIC 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) i, Stockton,California 95201 <br /> (209) 468-3400 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3420 <br /> 9=1U-r --IC1I Ft I Z AT I C [%J 'T C) RFEE IrIE✓ASE <br /> ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> It THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILI-�Y <br /> LOCATED AT 1745 2nd Street _Escalon, CA <br /> (STREET ADDRESS) (CI35� <br /> HEREBY AUTHORIZE Water kork rp, 1.0 Main �t_,Esscalon, CA 95320 (209) 838- 7 <br /> Co <br /> (LAPORATGRY or• CONSUL TANT)� <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/OPL, Robert M. Brayton <br /> EASE PRINTI (TI TLE) <br /> (SIGNRTUREI <br /> ADDRESS: P. 0. Box 95 <br /> (NAILING ADDRESS) <br /> Escalon CA _ 95320. <br /> (CI TY) (STATE) (ZIP) <br /> PHONE: —(.209 ) -..--a38-7388 <br /> DATE: <br /> EH 23 041 Revised 10/89 <br /> A Division of San Jotquin County Fle:rlrh Carr Scr.,irr< '�"� <br />