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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) Stockton, Califurnia 95201 <br /> cop�s' <br /> (209) 468-3400 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3420 <br /> AUTHOR I ZAT I ON TO RELIcFiSE <br /> * ANALYTICAL RESULTS <br /> at GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT s/lC kifL S9,,/W 7U) 6�4 <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE APPLi /Z C� t IFLF1/U'y�LG� '� lAx. <br /> (LABORATORY or CONSULTANT) <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: BKeA r� &450J�LTU3kAL S�RUtIOC, <br /> f (IF APPLICABLE) �7 7t� <br /> OWNER/OPERATOR: �L1)eT /�EL� fE'TH .5;M L/I WWPA7P� <br /> (PLEASE PR/INT) (TITLE) <br /> — 4�7 (SIGNATURE) <br /> ADDRESS: ( . �)r T-rX LCyL���7 <br /> (MAILING ADDRESS) <br /> S77-kf--,L-VMJ X24 9sZo/ <br /> (CITY) (STATE) (ZIP) <br /> PHONE: ( 2t'`^l) -'5-911 <br /> DATE: 7 /J <br /> EH 23 041 Revised 10/89 <br /> A Division of San Joaquin County Health Carr Servirrs 6""N <br />