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AUG- 3-90 FR I 10 ' 03 CAL I F . FIATURAL . PRf�U C TS <br /> • • <br /> PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY 1 <br /> I <br /> jOG1 KHANNA M,D„M,P.H. <br /> Hntrh Officer <br /> P.O.Pox 2009 • (1601 tact Hazelton Avenue) . Stockvun,Culifurniu 95201 <br /> (209) 468.3400 r <br /> ENVIRONMENTAL HCALTH DIVISION <br /> (209) 460^34RO <br /> F;4UyH0R x ZA-r T aN -ro Ike L.�Ai3Im <br /> of ANALYTICAL RESULTS <br /> * GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> It THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILI� y <br /> LOCATED AT In C7� e, I , -:-�-hRr`1r� Rd �� <br /> (STRAIT PDDRESS(r� i�� ) �r_P rC l'Y) <br /> HEREBY AUTHORIZE _ N-- _ <br /> (LAPORATORY or CONSUL TONT! <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 BOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS <br /> PROVIDED TO ME OR (My REPRESENTATIVE. <br /> BUSINESS NAMCI 1y( L3 <br /> (IF APPLICRRLE) <br /> OWNER/DPERATOR t �Q Clrino l � �p <br /> (PLqSC !� (TITL 1 <br /> (b4lUNPTURE) — <br /> aDDRE66� <br /> (MAILING RDARESSI ` "- <br /> fl� 45330 <br /> (CITY) t� ((STATE) (IIF) <br /> PHONEt _(Ed) - <br /> PATE I Q�X2� a ) q` cO <br /> CH 23 041 Roviood 16/49 <br />