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PUBLIC HEALTH SERVICES <br /> • SAN JOAQUIN COUNTY r.' �A� <br /> M.: ti '� •:t <br /> JOGI KHANNA M,D.t M.P.H. 1 '1 <br /> Health Officer <br /> P.O.Box 2009 . (1601 East Hazelton Avenue) . Stockton,California <br /> (209)468.3400 <br /> ENVIRONMENTAL HEALTH DIVISION APR 06 1990 <br /> ENV! <br /> (209) 468-3420ME�RAC H <br /> PERMR/SE EAQH <br /> AUTHO Ft I Z AT I ON TO RELLEAg ES <br /> �4Pnl: l�339oob2 * ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION Y <br /> r, <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT LO rIL�C.I &-uenUp. <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE L5CbY1Q10aA <br /> (LABORATORY or CONSULT ) <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: IY L��,{I1tteQ 1 ' <br /> (IF APPLICABLE) <br /> OWNER/OPERATOR: rV1,kr" 1 � &f OLZ 1I �h•Qjl/ <br /> (PL SE PRINT) (TITLE) <br /> (SIGNATURE) <br /> ADDRESS: u.— 1UYSIN % A <br /> (MAILING ADDRESS) <br /> (CITY) c (STATE) (ZIP) <br /> PHONE: _( �M) <br /> DATE: �a <br /> EH 23 041 Revised 10/89 <br /> A ' 1�1fM1 ��ti�1tl► ,lth Carte Scrvirt rO% <br />