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PUBLI2 HEALTH SER,%ICES 'O PQUiry%.0 <br /> SAN JOAQUIN COUNTY <br /> a: < <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer <br /> P.O.Box 2009 • (1601 East Hazelton Avenue) • Stockton, California 95201 <br /> (209)468.3400 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3427 <br /> AUTHORIZATION TO RELEASE <br /> • ANALYTICAL RESULTS <br /> • GEOTECHNICAL DATA <br /> • ENVIRONMENTAL/`.:ITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATEDAT 36 w, MgTf/Ew,S 2D�go /C/lEnt H Gigwt� <br /> HEREBY AUTHORI (Street Address) <br /> '5t�m G0 XW <br /> ZE <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: S I L V H T/t to c h I A)(� <br /> (If Applicab Ie) <br /> O WNER/OPERATOR: Dlq vl o S l i-v/g O y�vER <br /> (Please !) (Title) <br /> • (Signature) <br /> ADDRESS: 711z) w 144F/AtE <br /> (Mailing Address) <br /> STyekro.v cAc 9S�ay <br /> (City) (State) (zip code) <br /> PHONE: ( DO') 1 9??- / // l/ <br /> DATE: -7/ 2 3 I41 <br /> EH 23 041 (REV 2/8/91) wp Page 9 <br /> 4 Division of Sm jmquin County Hohh C r Semco <br />