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,- PUBL HEALTH SEFYICES <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.D.,M.P.H. � � '� <br /> Health Officer <br /> ast <br /> P.O. Box 2009 0 (1601 EHazelton Avenue) •Stockton, California 1 >< N 0101 P <br /> (209)468.3400 i <br /> ENVIRONMENTAL HEALTH DMSION ,o ff 2ID199 <br /> y <br /> (209) 468-3427 <br /> AUTHORIZATION TO RELEASE icFsyry <br /> • ANALYTICAL RESULTS <br /> • GEOTECHNICAL DATA <br /> • EWIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT �-o 'N" A01 i vt (Zy LL—Idl- <br /> (Street A s) (Cd}') <br /> HEREBY AUTHORIZE e-41 <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 lvfY REPRESEN'T'ATIVE. <br /> BUSINESS NAME: <br /> (If Applicable) <br /> OWNER/OPERATOR: <br /> (Please -41 <br /> t) Tule <br /> a <br /> r <br /> (Signa e) <br /> ADDRESS: Lq <br /> (Mailing Address) <br /> (C ,) (State) (zip code) <br /> PHONE: —76 L 1 . <br /> DATE: <br /> EH 23 041 (REV 2/8/91) wP Page 9 <br /> A Division of San Joaquin Counry Hcalth Care Services <br />