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PUBLIZ HEALTH SERVICES 0P`.,py 0o <br /> SAN JOAQUIN COUNTY c <br /> JOGI KHANNA MCD.,M.P.H. <br /> Health Officer <br /> c' r <br /> P.O. Box 2009 (1601 East Hazelton Avenue) Stockton,California 95201 eiFpp N� <br /> (209) 468-3400 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3427 <br /> AUTHORIZATION TO RELEASE <br /> ' ANALYTICAL RESULTS <br /> ' GEOTECHNICAL DATA <br /> " ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT FAA -ATC7,- 7`� a4��p�� <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE ���„n „�y„/I �^,� ) y <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: F . �99A1 mAT/ojJADHjg MBFIC CQNTR61- ToWiL% <br /> (If Applicable) <br /> OWNER/OPERATOR: p <br /> (please pri t) (Tide) <br /> (Signature) ✓ <br /> ADDRESS: &,&mo gZOO7 <br /> (Mailing Address) <br /> (City) o (State) (zip code) <br /> PHONE: (_2_J_3 ) 29 rf— <br /> DATE: <br /> Eli 23 041 (REV 2/8/91) wp Page 9 <br /> A Division of San Joaquin Counry Health Care Services <br />