Laserfiche WebLink
03-01 91 o, DO PM FROM INC, 455-4995 i� �• ruc <br /> PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> .�. JOGI KHANNA M.R.M.P.H.;p <br /> HealthOffieer <br /> P.O. Box 2009 + (1601 East Hazeiton Avenue) . Stockton,Califueniu 95201 <br /> (709) aha-5400 J <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (E09) 468-34E0 <br /> ;i <br /> AU-rHC'IR X ZA`r I ON Tr© RELMAE30 <br /> ANALYTICAL RESULTS" <br /> * GEOTECHNICAL DATA <br /> i� <br /> • ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> 11 THE UNDERSIGNEQ OWNER AND/OR OPERATOR OF THE PROPERTY AND/QR FACrILITY <br /> LOCATED AT Zoj <br /> mmErr ADDRL:ss) GCrrr) <br /> HEREBY AUTHORIZE Vr►a.�-- �"1G <br /> (LABORAYORY or C0N6iJL rANT) I <br /> TO RELEASE ANY AND ALL ANALYTICAL RESULTS, GEOTECHNICAL DATA AND/OR F <br /> R N <br /> �ENVIRCNMENTAL/SITE ASSESSMENT INFORMATION TO USAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES AS SOON AS IT IS AVAILABLE AND AT THE SAME T;ME IT IS <br /> PROVIDED TO ME OR MY REPRESENTATIVE. <br /> ~ <br /> BUSINESS NAME <br /> T <br /> (IF APPLICABLE) <br /> OWNER/ORERATGR w EF (Tr71E) <br /> PRINT) <br /> i� <br /> Q (aSIGNATCIRE) <br /> (MAILING ADDRESS) <br /> (c rr) a E eaTATE) (rrp) <br /> PHONE s �(��� 3 G af3�-8?•�-�S� <br /> DATE s <br />