Laserfiche WebLink
PUBLIC <br /> HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.D.,M.P.H. viii <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) 468-3420 <br /> AUTHORIZATION TO RELEASE <br /> * ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> r, <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT Q <br /> (STREE�DDRESS) 24A�AZl <br /> HEREBY AUTHORIZE � y <br /> (LABORATORY or CONSUL Ti4NT) <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: 2 CAL— ' <br /> (IF APPLICABLE) <br /> OWNER/OPERATOR: L/ <br /> (P EASE PRINT (TITLE) <br /> (SIGNATURE) <br /> ADDRESS: lo� CD <br /> (MAILING 7ZSJ <br /> (Cl TY) (STATE) (ZIP) <br /> PHONE: _( ) �o �� 36�-' <br /> DATE: .-/ <br /> EH 23 041 Revised 10/89 <br /> A Division of San Joaquin County Healrh Carr Cervicra <br />