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Lit HEALTH SEIICESPUB <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA I.D.,1NI.P.H. <br /> Health Officer <br /> P.O. Box 2009 (1601 East Hazelron Avenue) • Stockton,California 95201 �'FORa <br /> (209) 468-3400 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 4bS-3427 <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 I(Oo,5 e u—W e.L_ gogApp AV lei E ST 4 <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <br /> (Laboratory or Consultant) <br /> TO RELEASE ANY AND ALL ANALYTICAL INFORMATION TO SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: Exo�aN STATIDN <br /> (Jf Applicable) <br /> OWNER/OPERATOR: 6[ISE(1 O F M1A R Z0 <br /> (Please Print) (Title) <br /> — <br /> (SiQ ature) <br /> ADDRESS: 230LA ON RO- ITE IM O <br /> (Mailing Address) <br /> c�aN CA <br /> (City) (State) (zip code) <br /> PHONE: ( SIO ) Z4-4p— & Z(o <br /> DATE:.x- 1!4 R Z <br /> EH 23 041 (REN 2/8/91) wp Page 9 <br /> A Division of San Joaquin County Heairh Care Services <br />