Laserfiche WebLink
H r�wo;Lok W <br /> PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY 2: z <br /> Q: <br /> JOGI KHANNA M.D.,M.P.H. 0 <br /> 1 <br /> Health Officer <br /> P.O. Box 2009 . (1601 East Hazelton Avenue) Stockton,California 95201 <br /> (209) 468-3400 ,. <br /> - <br /> ENVDEC <br /> � if �.19 <br /> ENVIRONMENTAL HEALTH DIV I S I ON IR���AEfE �-AL <br /> (209) 468-342c) PSR OIT/SERVIHES LT,' <br /> AUTHO R I Z AT I OthJ -r C) IREII--:"SIC <br /> ANALYTICAL RESULTS <br /> GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> I, THE UNDERSIGNED OWN/ER AND/OR OPERATOR <br /> OF THE <br /> P'ROP'ERTY AND/OR FACILITY <br /> LOCATED AT STxz" /d <br /> (STREET /ADDRESS) / T (CITY) <br /> HEREBY AUTHORIZE AEPIr �.✓or.�o ��z.✓fe� Con/aa< .✓�____' _ --------__ �___._—__ <br /> (LPBOR#QTORY or, CONSULTONT) <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION TO SAN JOAQUIN 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: C,e I o,�.VIA FL/ <br /> (I F APPLICABLE) <br /> OWNER/OPERATOR: /I2e rC/moo did NTt./,off - -----.--------------'` /t' �--- <br /> (PLEASE PRINT) (TITLE) <br /> (SIGNATURE) <br /> ADDRESS: '60iY <br /> (MOIL ING /ADDRESS) <br /> (CITY) (STATE) (ZIP) <br /> PHONE: —( O9! ) W61- <br /> DATE: <br /> EH 23 041 Revised 10/89 <br /> A Division of San Joaquin County Hrilth Care Services <br />