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PUBLIC HEALTH SERVICES <br /> SAN JOAQUIN COUNTY <br /> JOGI KHANNA M.D.,M.P.H. <br /> Health Officer <br /> P.Q.Box 2009 . (1601 East Hazelton Avenue) . Stockton,California 95201 <br /> (209)468-3400 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> (209) 468-3420 <br /> AU'THC3 R I Z ATI C3M TC] FkEI—EASFEE <br /> ANALYTICAL RESULTS <br /> * GEOTECHNICAL DATA <br /> ENVIRONMENTAL/SITE ASSESSMENT INFORMATION <br /> Ir <br /> I, THE UNDERSIGNED OWNER AND/OR OPERATOR OF THE PROPERTY AND/OR FACILITY <br /> LOCATED AT ,.QUO GAJ. /1A-` y <br /> (STREET ADDRESS) (CITY) <br /> HEREBY AUTHORIZE S .� ivc <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: _., 14-e'li2i9 Sr . <br /> (IF APPLICABLE) <br /> OWNER/OPERATOR: —.4z— <br /> (PLEASE <br /> __ <br /> U.eQ J_ Ee.c .�i cert!) SP.e„vG ,Q, E.c�v �9�fi11.es <br /> (PLEASE PRINT) (TI TLE) <br /> (SIGNATURE) <br /> ADDRESS: 10.5-Z' "G� <br /> (MAILING ADDRESS) <br /> Uz u v a�5 G' 9.�aa <br /> (CI TY) (STATE) (ZIP) <br /> PHONE: J3/ -6667 <br /> L <br /> DATE: <br /> EH E3 041 Revised 10/89 <br /> A Division of San Joaquin County Hrilrh Care Servieri <br />