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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.D.,M.P.H. X <br /> Health Officer <br /> A,� <br /> P.O. Box 2009 . (1601 East Hazelton Avenue) . Stockton, California 95201 kiF- <br /> (209) 468-3400 -, <br /> Lo /t e <br /> A10 <br /> ENVIRONMENTAL HEALTH DIVISION EA✓�jPr V 131989 <br /> Mia <br /> (209) 468-3420 P' N✓Itr <br /> �t'hl)�!'JTq( �F <br /> AU-r M R I Z AT I MP4 TO REI_FEE 9=bE E <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 �� �:� S, /f�, A1i7A4 2e9,';'YJ <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE GTS// Ac'itiC. ,,t/ <br /> (LABORATORY or, CONSULTANT) <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 /> (IF APPL I CABLE) <br /> OWNER/OPERATOR: <br /> EASE PRI T) (TITLE) <br /> (SIGIVATURE) <br /> ADDRESS: 11�71� h <br /> (RAILING ADDRESS) <br /> (CITY) (STATE) (ZIP) <br /> PHONE: <br /> DATE: /v . <br /> EH 23 041 Revised 10/89 <br /> A Division of San Joaquin County Health Care Service~ <br />