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JAN- 6-93 WED 8:47 __ SLAKEV BROTHERS FAX N0,�91649320nry P ea <br />1•t R �,• <br />PUBLIC , HEALTH <br />SERVICES VICES <br />,.JG*,Qq1N COUNTY <br />_ r <br />JOG1 KHANNA MA HRH r <br />�,'•,; .1 • P.O. Ear 20 9 t (1601 Eau HAZ01904 Avenue) • Suxiton, Cali(ornh 95201 <br />ENVIRONMENTAL HEALTH DIYISION <br />(209) 46&3427 <br />-AUTHORIZATION TO RELEASE <br />ANALV11CAL RF,$ULTS <br />' GEOTECHNICAL BATA <br />' ENVIRONMENTALlsl-l� ASSESSMENT INFORMATION <br />1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br />LOCATED At 1 ('t'7 ;r, G' - R . - r _ „ I n <br />HEREBY ALTKORIzE <br />TO RELEASE ANY ANE <br />HEAL 1 i J SERVICES AS SOON AS 1T IS AVAILA$I E ANp p7 THE 5,1-1,I$ TIME 1T IS YROV1DED <br />TO ME OR MY REPRESENTATIVE. <br />c <br />BUSINESS NAME-- <br />OWNER/OPERATOR; <br />AME OWNER/OPERATOR; DahgG / /�f " <br />(Plr Prier) rtle) <br />gn re) <br />ADDRESS: !r o%6— QGt/� ��✓� <br />(Halling Addrars) r <br />S,9c 70. <br />c� (ury1 (Stare) (zip rade) <br />DATE: , <br />Ell 23 041 (REV 3/g/91) r p I <br />Fait 9 t <br />nteyq jo.go7n Caonq Neahh Gn9errka� 'r F <br />.r:, iy...i h`.•• , :�..° `4,R5 •: a.•. f.. "P .'v 3. •'• •' t.v. + .. <br />.. ~R lig <br />