Laserfiche WebLink
PUBLIC <br /> HEALTH <br /> SAN JOAQUIN COUNTY 2: <br /> ~� JOGI KHANNA M.D.,M.P.H. " �X <br /> Health Officer <br /> P.O. Box 2009 . (1601 Easr Hazelton Avenue) • Scuckrun, California 95201 FOpa <br /> (209) 168-3400 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ( 09) 468-34220 <br /> ALJTHOR I ZAT I ON TO Ra:L-1=—ASE <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 63 QI Wet ��0. S+re�,�- St oG��-�b S 2--(Dr.:, <br /> (STREET ADDR SS) (CI TY) <br /> HEREBY AUTHORIZE K� IfJ�E(�L7!✓� �'`'���ofz acPPL (- p, (�0��7ue-1 CS <br /> (LABORATORY or- CONSULTANT) <br /> TG 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: V\J S T CLA' A PE-P-7-1 ES I (,J C <br /> ?IF APPLICABLE) <br /> OWNER/OPERATOR: <br /> RLEASE PRI,VT) (TITLE) <br /> (SIGNATURE//) <br /> ADDRESS: <br /> (MAILING ADDRESS) <br /> 5 7 Zx- <br /> (CI TY) (STATE) (ZIP) <br /> PHONE: T3`3 D 3 O Z <br /> DATE: <br /> EH u3 041 Revised 10/89 <br /> A Division of San Joaquin County Hevlrh Cj re�ervict" <br />