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PUBLIC HEALTH SERVICES _ <br /> SAN JOAQUIN COUNTY r: <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer <br /> P.O. Box 2009 . (1601 East Hazelton Avenue) . Stockton,Callfurnla 95201 <br /> (209) 468-3400 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 466-3420 <br /> A U T H O R I Z A T I O N T C3 R E L E A S E <br /> * ANALYTICAL RESULTS <br /> * GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/ORFACILITY <br /> LOCATED AT 67-57 W QST ( r' ST— "PACy ) 6,4 <br /> (STREET ADDRE8SIGF0��(( (CITY) <br /> HEREBY AUTHORIZE �EcEtN��S <br /> _ (LABORATORY at, 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: D(e'^^MDwt3 Vko?EeTItz-S <br /> (IF APPLICABLE) `J� <br /> OWNER/OPERATOR: ��" l�lS7�/c 7 Y <br /> ( LEASE PRINT) (TITLE) <br /> S GNATUREI /� ``'' <br /> ADDRESS: 2- DF::— Sry <br /> (NAILING ADDRESS) <br /> SAr/ RAMOnl C4 94583 <br /> (CITY) (STATE) (ZIP) <br /> PHONE: _(415—) <br /> DATE: <br /> EH 23 041 Revised 10/89 <br /> A Division of San Joaquin County Hnlrh Care Services <br />