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rfE= SERO 7ICES <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.D.,M.P.H. y: y <br /> Hath Officer <br /> P.O. Box 2009 . (1601 Easr Hazelton Avenue) . Stockrun, Califurnia 95201 � <br /> 9 ,FQ{1 N <br /> (209) 468-3400 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3420 <br /> AIUTHa R I Z ATI C3 p4 TO Re:L- E <br /> * ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/Oh FACILITY <br /> LOCATED AT ,os7 v Nc <br /> (STREET ADDRESS) <br /> HEREBY AUTHORIZE (CITY) <br /> f,✓ur n �� ,, J <br /> TO RELEASE ANY AND ALL ANALYTICAL(LABORATORY RESULTS,' GEOTECHNICAL DATA AND/OR <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO SAN JOAUUIN COUNTY PUBLIC <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: �',,� ,�Aw*tA I-16-11,1 <br /> (IF APPLICABLE) <br /> OWNER/OPERATOR: 122c 441""/ <br /> (PLEASE PRINT) (TITLE) <br /> (SIGNAT/JRE) . <br /> ADDRESS: <br /> (MAILING ADDRESS) <br /> s�or / <br /> ',e c 3! 20 <br /> (Cl TY) (STATE) (ZIP) <br /> PHONE: _(12 Q ) y6/6/ <br /> DATE: <br /> EH 23 041 Revised 10/89 <br /> A Division of Sjn Joaquin Counry Ffeilrh Care_Services .. <br />