Laserfiche WebLink
PUBL HEALTH SERVICES oPa N. <br /> SAN JOAQUIN COUNTY r. <br /> JOGI KHANNA&f.D.,M.P.H. ?I ` <br /> Health Officer ' <br /> P.O. Box 2009 . (1601 East Hazelton Avenue) • Stockton,California 95201 cQciFoa� P <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 /> 1, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT ('ofo y9 Em �XeI'CE,rp ,�r,✓� S'pck�peit <br /> (Street Address) (City) <br /> HEREBY AUTHORIZE -Ge-,L> <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 1T IS PROVIDED <br /> TO ME OR MY REPRESENTATIVE. <br /> BUSINESS NAME: (A dct 9 e- We,S 7�- er7o V't h C,.,_ <br /> (If Applicable) <br /> OWNER/OPERATOR: h �yh �k e_ �yf�ygS <br /> (Please nt) (Title) <br /> (Signature) <br /> ADDRESS: Pd/aq>- k,k--6 IrA ri,4c` <br /> (Mailing Address) <br /> kay ah <br /> (City) (State) (zip code) <br /> PHONE: (A09 <br /> DATE: <br /> Eli 23 041 (REV 2/8/91) wp Page 9 <br /> A Division of San Joaquin County Health Care Services <br />