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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer , <br /> P.O.Box 2009• (1601 East Hazelton Avenue) •Stockton, CaEfamia 95201 4ci coal <br /> (209)46&3400 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3427 <br /> AUTHORIZATION TO RELEASE <br /> • ANALYTICAL RESULTS <br /> • GEOTECHNICAL DATA <br /> * ENVIRONMENTAL 1TE ASSESSMENT INFORMATION <br /> I,THE UNDERSIGNED OWNNER/A1N�D/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATEDAT q30 l�{ \DI IMJ�V i SLU l� <br /> rr��,S eet Address) , (city) <br /> HEREBY AUTHORIZE r(T �nU12Dl"ML I <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... 11 (� <br /> BUSINESS NAME: � u _ �A Yk e 11 <br /> (If Applicable) T <br /> OWNER/OPERATOR: <br /> (Pleas Print) (Title) <br /> ( aature)) y ': v�J— <br /> ADDRESS: "(tr /y L."-f <br /> (Mailing Address) <br /> Lola I <br /> (City) (State) (zip code) <br /> PHONE: <br /> DATE: Hag" <br /> EH 23 041 (REV 2/8/91) wp Page 9 <br /> A Division of San Joaquin County Health Cs c Services <br />