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PUBLIC <br /> HEALTH <br /> SERVICES Q�,N <br /> SAN JOAQUIN COUNTY <br /> »; <br /> JOGI KHANNA M.D.,M.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) 468-3420 <br /> AUTHO F2 I Z AT I ON TO F2ElLEAiSE <br /> ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> r, <br /> Is THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT ///)0- ) /,a <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE 111L S, 72C,00u"C-C&Z � ,� ;nnAj.-f rAAd <br /> (LABORATORY or• CONSUL TAN T) <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: Z, -/ /1�• c P - es1"e- <br /> (IF 4PPLICRBLE) <br /> OWNER/OPERATOR: Ace/ <br /> f TIEASE PRINT) LE) �4 est <br /> ttt6�ti-- <br /> (SIGNATURE) <br /> ADDRESS: Vr.ss <br /> (MAILING ADDRESS) <br /> (CITY) (STATE) (ZIP) <br /> PHONE: —02-3-) <br /> DATE: $ g <br /> EH 23 041 Revised 10//89 <br /> A Division of Son Joaquin County Health Carr Cervicec <br />