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PUBLIC HEALTH SERVICES <br />O'O.0 IN C <br />SAN JOAQUIN COUNTY r; y <br />JOGI KHANNA M.D., M.P.H. <br />Health Officer <br />P.O. Box 2009 . (1601 East Hazelton Avenue) . Stockton, California 95201 • �'4. ;go n0s� <br />(209)468.3400 <br />ENVIRONMENTAL HEALTH DIVISION <br />(209) 468-3420 <br />'P4u-rHOR I ZAT I ON 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 ,z�.?�/ y <br />HEREBY AUTHORIZE <br />(STRE T PDDRESS) <br />(CITY) <br />(LnB <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: <br />OWNER/OPERATOR: <br />ADDRESS: <br />(IF PPPLICRBLE) <br />(M,QILING PDDRESS) <br />(CITY) <br />PHONE: _( ) <br />EH 23 041 Revised 10/89 <br />A Division of San Joaquin %unry Healr6 r... q—. ;... *q' -N <br />(TITLE) <br />(STq TE) (ZIP) <br />