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PUBLIC HEALTH SEfVICES <br /> OPp.U1N C <br /> SAN JOAQUIN COUNTY r. <br /> JOGI KHANNA M.D.,M.P.H. ":_ ! ?� <br /> Health Officer <br /> q� <br /> P.O. Box 2009 . (1601 East Hazelton Avenue) . Stockton,California O <br /> (209)468-3400 RECEIV <br /> OCT 11 1440 <br /> ENVIRONMENTAL HEALTH D I V 131 ON ENVIRONMENTAL HEALTH <br /> (209) 466-340 PERMIT/SERVICES <br /> AUTHO R I Z AT I C3P4 TO REI___FEE OP4EE <br /> ANALYTICAL RESULTS i <br /> GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER <br /> �AND/OR OPERATOR OF THE PRPROPERTY AND/OR FACILITY <br /> g <br /> LOCATED AT / /99 c>, 4UISTr/1 ,1;1(. .__._..I�lq-aAleCGx_/:5J,),c YL _.__..._.... ..._. <br /> ..... . ....... <br /> (STREET ADDRESS) _ i C I TY. <br /> HEREBY AUTHORIZE <br /> (LABORATORY or CONSULTANT) <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO SAN .JOAQU I N 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: <br /> (IF APPLICABLE) <br /> OWNER/OPERATOR: L Or,-/ AGA 5w)_..__...-- <br /> 65 PRINT) i T'I TLE) <br /> (SI ) <br /> ADDRESS: - <br /> (NAILINS ADDRESS) <br /> S-/Z)cl ____ <br /> XI TY) (STATE) ( IP) <br /> PHONE: ^(209 ) -466- 6192 <br /> DATE: A-,)O <br /> EH 23 041 Revised 10/89 <br /> A Division of San Joaquin County Health Cure Services <br />