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PUBLIC HEALTH SERVICES <br /> p'O,V!N C <br /> SANJOAQUIN COUNTY <br /> JOGI KHANNA M.D.,M.P.H. X <br /> Heahh Officer <br /> P.O. Box 2009 , (1601 East Hazelton Avenue) • Stockton, California 95201 <br /> (209) 468-3400 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3420 <br /> AUTHORIZATION TO RELEASE <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 6Jou�k <br /> (STREET ADDRESS) n/ (CITY) <br /> HEREBY AUTHORIZE 3r&'O � o Cho. <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: Lick __4 ( (4 na <br /> —T �/ ' d (IF APPLICABLE) <br /> OWNER/OPERATOR: .Tett O�rhe-�- Ue� <br /> (PLEASE PRINT) (TITLE) <br /> (SIGNATURE) // <br /> ADDRESS: 10c/S .S.• 7171 (f L'zr/' � p <br /> (MAILING ADDRESS) <br /> Lo d ; <br /> (CITY) (STATE) (ZIP) <br /> PHONE: _( ) 331 - bSoO <br /> DATE: <br /> EH 23 041 Revised 10/89 yp� <br /> A Division of San Joaquin Counry HeArh Care Services • r <br />