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PUBLtlol <br /> HEALTHSERVICES <br /> SANJOAOINCOMY <br /> ...� JOq KHANNA ILD,kPit r <br /> P.O.Boz 2009 • (1601 East Hazelton Avenue) . Stockton.Caliro" 95201 <br /> (209)468.3400 <br /> m <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ('209) 468-342o <br /> AUTHO R I ZA-r I C3M TO RELEASE <br /> +� ANALYTICAL RESULTS ,0 <br /> * GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/8ITE ASMSSMENT INFORMATION �F'�'9p ����► <br /> 'L,,,Fy�G, � �► <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY-AND/OR FAds� <br /> LOCATED AT <br /> tSTREET �� �� <br /> HEREBY AUTHORIZE o DJC + ICITYJ <br /> � TO RELEASE ANY AND ALL ANALYTICAL �T� <br />.� DATA AND/OR` <br /> ENVIRONMENTAL/SITE ASSESSMENT IWO TtpN To SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS <br /> PROVIDED TO bit OR MY REPRESENTATIVE. <br /> BUSINESS NAME: 1/ <br /> f IF Ac'FK.1'CASLEJ <br /> OWNER/OPERATOR: <br /> (PLE E <br /> (TI TLE) <br /> SIGNATOR / . <br /> ADDRESS: O <br /> . IMRILING ADDRESS! <br /> (CITY) ISTgTE) (ZIF') <br /> PHONE: azi <br /> DATE: <br /> EH 23 041 Revised 10/89 <br /> A Oivition of 8m j_nnin Crnmw <br />