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AMW <br /> A Y <br /> f <br /> PUBIIC <br /> HEALTH SRVICES '4 ..... <br /> SAN JOAQUIN COUNTY ka""`�' 71. <br /> JOG[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) 468-3420 <br /> A U T H O R I Z A T I O N -11­0 R E L—EA EE <br /> * ANALYTICAL RESULTS <br /> * GEOTECHNICAL DATA <br /> * ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> r; <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT .205 1 ? , <br /> fREEX ADR SSI <br /> HEREBY AUTHORIZE1j26CITY) <br /> (LAPORATORYdO, CONSUL Ti4NT) <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO SAN JOAQUIN COUNTY PUSLIC <br /> HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME TIME IT IS <br /> PROVIDED TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: �� <br /> (IF APPLIC EJ <br /> OWNER/OPERATOR: lies <br /> / T� <br /> (P EASE PR IN 1 (TITLE) <br /> (SIGNATURE) <br /> ADDRESSz c9ns l 111i <br /> (MAILING ADDR SS) <br /> (CITY) I (STATE) (ZIP) <br /> PHONE: _(a) <br /> DATE: <br /> EH 23 041 Revised 10/89 <br /> A Division of San tn.n„;n u-.,►o.�...,, <br /> } <br />