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PUBLIC HEALTH SERICES <br /> SAN JOAQUIN COUNTY r. z <br /> JOGI KHANNA,\1.D.,M.P.H. <br /> Healch Officer qP. <br /> P.O. Box 2009 (1601 Fast Hazelton Avenue) • Stockton, California 95201 er r;D aN <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 I W& ab6T MSH 12Toc.lc.To r-1 <br /> (Street Address) Pry) <br /> HEREBY AUTHORIZE TT co9.W9^SI0r% <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: 8P 0"I FRc.lt �IIgD <br /> (If Applicable) <br /> OWNER/OPERATOR: CHch i�iL Lac tyntGCT / ArLT /I/UINltel <br /> F+►r (Please Print) (Title <br /> azure) <br /> ADDRESS: 7803 MAO /4 A,)inr 320 <br /> (Mailing Address) <br /> (City) (State) (zip code) <br /> PHONE: 9( l(o ) ` u" —`loll <br /> DATE: <br /> EH 23 041 (REV 2/8/91) wp Page 9 <br /> A Division of San Joaquin Cowry Hca1N C rc Services <br />