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PUBLIC41JEALTH SEMTCES <br />SAN JOAQUIN COUNTY <br />y: z :< <br />JOGI KHANNA KD., Nf.P.H. <br />Health Officer <br />P.O. Box 2009 • (1601 East Hazelton Avenue) • Stockton, California 95201 <br />(209)468-3400 <br />ENVIRONMENTAL HEALTH DIVISION <br />(209) 463-3427 <br />AUTHORIZATION TO RELEASE <br />* ANALYTICAL RESULTS <br />* GEOTECHNICAL DATA <br />* ENVIRONMENTALISITE ASSESSMENT INFORMATION <br />I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED AT 2 31 S Ttzoc� E)L-\ > T24G <br />(Street Address),1 (City) <br />HEREBY AUTHORIZE Rzeci SIOn ANALYTic,�t_ <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: 1fP OIC.- Cp <br />(If Applicable) <br />OWNER/OPERATOR: C 1-► S c.,—l-` I,-- _ _ F NnIc=TT Pwcs MkAk4R-�. <br />(Please Print) (Title) <br />V _- <br />(Signature) <br />ADDRESS: 2060 huNCLtsF— Bt_vD & WC,, <br />(Alailing Address) <br />v at,i CN , (,b 95114 Z <br />(City) (State) (zip code) <br />PHONE: ( '91(p ) 4,35 - 24 -4 -4- <br />. <br />44 -4 - <br />TAN . 2 01,91 <br />EH 23 041 (REV 2/3/91) wp Page 9 <br />A Division of San Joaquin County Healch Care Services fo <br />