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PUBLIC HEALTH SERVICES ,0iQku!jy: <br /> SAN JOAQUIN COUNTY a 1� <br /> JOGI KHANNA M.D,NIT H. <br /> Health Officer ., w <br /> P.O. Box 2009 • (1601 East Hazelton Avenue) • Stockton,California 95201 <br /> (209) 468-3400 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-342-1 <br /> AU'T'HORIZATION TO RELEASE <br /> * ANALYTICAL RESULTS <br /> • GEOTECHNICAL DATA <br /> 1' ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT r/10 C&jr- Pr Sfarkfoi✓ <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE <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: <br /> (If Applicable) <br /> p <br /> OWNER/OPERATOR: f1�L lN,5a WCL <br /> (Pliase Print) (Title) <br /> (Sig ature) <br /> ADDRESS: <br /> (Mailing Address) /7�j� /, <br /> Tom)G1Z77IV C — �I 5 ZG) <br /> (city) C� (( (State) (zip code) <br /> PHONE: ( (�%) 1 7 T 2, 6a <br /> DATE: <br /> EH 23 041 (REV 2/8/91) wp Page 9 <br /> A Division of San Joaquin Cowry Hcalth Cue Scmc" �� <br />