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PUBLIC HEALTH SERVICES o�4 ••.c <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer <br /> P.O. Boz 2009 . (1601 East Hazelton Avenue) . Stockton,California 95201pP <br /> ' ' <br /> (209) 468-3400 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3420 <br /> AUTHORIZATION 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 1766 Monte Diablo Avenue , Stocl-ton <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE Roger Foott Associates , Inc . <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 APPLICABLE) <br /> OWNER/OPERATOR: Mr . Russell F. Chapin Owner <br /> (PLEASE PRINT) / (TITLE) <br /> (SIGNP TURF) <br /> ADDRESS: 1203 North Carlton Avenue <br /> (MAILING ADDRESS) <br /> Stockton California 95203 <br /> (CI TY) (STATE) (ZIP) <br /> PHONE: _( ) <br /> DATE: <br /> EH 23 041 Revised 10/89 <br /> A Division of San Joaquin County Health(are Servicei <br />